Microsoft word - adult consent form 2013

Clinic Site: __________________________ Flu Prevention Program
Patient Name
Date of Birth
(As it appears on insurance card)
Age: _________
No. and Street Name (No PO Box Please)
City State Zip
Home or Cell Phone:
Work Phone:
PRIMARY INSURANCE INFORMATION: Please check your insurance; fill in your insurance ID# and policyholder’s name.
Insurance ID
Name of insured person if other than patient: ________________________________________________________

Direct Payment:
Additional Medicare Plan: ______________________________ This is a Medicare Advantage Plan
Policy #: __________________________________________________ I understand I will receive a bill from WCHC for any portion of this claim my insurance company
does not pay and I agree to pay the bill in full within 30 days of receipt.
1. Have you had a severe allergic reaction (including but not limited to hives) to eggs, latex or the preservative thimerosal? 2. Have you ever had a reaction to any vaccine? If yes, which vaccine. ______________________ Yes No 3. Have you ever been diagnosed with Guil ain-Barré Syndrome? 4. Are you sick with a fever of >100 degrees today? UNDER AGE 50 ONLY: Answer the following ONLY if you are interested in receiving FLUMIST.
A. Do you have chronic health issues such as: diabetes; heart, lung, kidney or liver disease; COPD or asthma, or a neuromuscular/neurological diseases? B. Are you in close contact with an immunosuppressed person who requires protective isolation? C. Are you pregnant or is there a chance you might be pregnant? D. Have you taken an antiviral medication such as Tamiflu® or Relenza® within the last 48 hours? E. Have you been immunized with a live vaccine (MMR, chicken pox, shingles, yellow fever or oral typhoid) I have read the Influenza Vaccine Information Statement dated 07/26/2013. I have had a chance to ask questions and I understand the benefits and risks of the vaccine. I request that the vaccination be given to me (or to the person for whom I am authorized to make this request). I authorize the release of any medical or other information necessary to process the insurance claim or for other public health purpose. I have read the Notice of Privacy Practices. I agree to pay all unpaid charges billed to me by Western Connecticut Home Care.
Signature: ________________________________________ Print Name: ________________________________________

Place vaccine label here or complete:
Vaccine Brand:______________________________ Lot #: ___________________ Exp. Date:____________
Site: L Arm R Arm Intranasal
Administered by: ___________________________
Date: ______ / ______ / ______


Microsoft word - 2006-pb-20_goodman.doc

2006-PB-20 December 2006 Consumer Directed Health Care John Goodman Abstract: Consumer driven health care (CDHC) is a potential solution to two perplexing problems: (1) How to choose between health care and other uses of money, and (2) how to allocate resources in an industry where normal market forces have been systemically suppressed. In the consumer-driven model, consumers

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