Get Pneumococcal Polysaccharide Addendum - Texas Department Of ... - Dshs Texas

Navigating the Pneumococcal Polysaccharide Addendum can be straightforward with the right guidance. This document is essential for individuals seeking to obtain the pneumococcal vaccine and provides necessary consent and information.

Follow the steps to accurately complete the addendum online.

1. Press the ‘Get Form’ button to access the Pneumococcal Polysaccharide Addendum and open it for editing.
2. Begin by reviewing the first section, which requires you to confirm that the individual named below will receive the vaccine. Ensure the details are accurate before proceeding.
3. In the next section, acknowledge that you received or were offered the Vaccine Information Statement (VIS) related to the vaccine you are filling out the form for. This is crucial for informed consent.
4. Confirm your awareness of the risks associated with the disease being vaccinated against. This statement emphasizes the importance of understanding the need for immunization.
5. You will also need to acknowledge your understanding of the benefits and risks associated with the vaccine itself. This ensures you are making an informed decision.
6. Indicate that you have had an opportunity to ask questions regarding the disease, the vaccine, and the administration process. Clear communication is key.
7. Confirm your capacity to consent as an adult for the individual receiving the vaccine. You must freely and voluntarily provide your signature here.
8. Fill in the Provider Identification Number and Medicare Health Insurance Claim Number, as these are necessary for processing.
9. Next, provide information about the person receiving the vaccine. Fill in their full name, birthdate, sex, and address details accurately.
10. Record the date the vaccine was administered, along with the vaccine lot number for tracking purposes.
11. The individual receiving the vaccine or their authorized representative (e.g., parent or guardian) should provide their signature.
12. The vaccine administrator must sign and date the form, including their title, to validate the vaccination process.
13. Finally, review all the information on the form to ensure accuracy. Once verified, you can save changes, download, print, or share the completed form as needed.

Start completing your Pneumococcal Polysaccharide Addendum online today!