Get 0-18 Years Of Age Vaccine Documentation/consent Form

Completing the 0-18 Years of Age Vaccine Documentation/Consent Form online is an essential step in ensuring that individuals receive the necessary vaccinations. This guide provides clear and supportive instructions to help you navigate each section of the form with confidence.

Follow the steps to successfully fill out the form online.

1. Press the ‘Get Form’ button to access the 0-18 Years of Age Vaccine Documentation/Consent Form and open it in your online editor.
2. Begin by entering the patient’s first name, middle name, and birth date in the designated fields. Include ethnicity if requested.
3. In the demographics section, fill out the last name, age, and answer whether the patient identifies as Hispanic. Select the gender option that applies.
4. Provide the mailing address, including apartment number, city, state, county, and zip code.
5. If applicable, enter the mother's first name, last name, and phone number for contact information.
6. Indicate if immunizations are covered by health insurance by selecting yes or no. If no, be aware of the requirement for a written statement from the insurance company.
7. Fill in the insurance billing information: the primary insurance carrier's name, ID number, group number, the policy holder’s name and birthdate, and their relationship to the patient.
8. Sign and date the authorization statement to allow the Riley County Health Department to bill medical payers as indicated.
9. Complete the VFC eligibility section based on the patient’s insurance coverage.
10. Answer the immunization screening questionnaire carefully, indicating yes or no for each question related to the patient's health history and any current health issues.
11. In the vaccine consent section, check the appropriate vaccines desired for the patient and confirm that you have read the Vaccine Information Statement(s).
12. Add your signature and date to finalize the consent, ensuring all sections are filled out accurately.
13. After reviewing all information, save your changes, and choose to download, print, or share the completed form as necessary.

Start filling out your 0-18 years of age vaccine documentation/consent form online now!