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  • Influenza (flu) Vaccine Consent Form

Get Influenza (flu) Vaccine Consent Form

Ne Physician Name/Location 1. Do you have or have you ever had an allergy to eggs or egg products? Yes No 2. Have you ever been diagnosed with Guillain Barre syndrome (a progressive paralysis that goes away after a period of time)? Yes No 3. Are you pregnant? Yes No 4. Do you have any allergies to medication or food? What? Yes No I have read the information about the influenza (flu) vaccine and I feel that I should receive this immunization. I.

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Children younger than 6 months of age are too young to get a flu shot. People with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine. This might include gelatin, antibiotics, or other ingredients.

ICD-10 requires only one code (Z23) per vaccination, regardless if single or combination. Report Z23 for all vaccination diagnoses.

90686, “Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use.” 90688, “Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use.”

Influenza vaccine precautions: Moderate to severe illness with or without fever (temporary precaution). History of Guillain-Barre syndrome after influenza vaccination. History of a severe allergic reaction to a different type of flu vaccine.

It is important to note that employees need to be properly informed of the benefits of the vaccinations. However, although OSHA does not specifically require employees to take the vaccines, an employer may do so.

ICD-10 code Z23 is reported for vaccine-related encounters for all vaccines given within the encounter. Z23 is the ICD-10 code that identifies an encounter for immunization(s).

Use the CPT code for the vaccine administered (90686) and link to the diagnosis code for the immunization. Because qualified counseling occurred for a patient younger than 18 years of age, bill 1 unit of 90460 for administering influenza vaccine.

Therefore, when a clinician orders testing for influenza A and B, CPT® 87400 is used twice, once for influenza type A and once for influenza type B. 59. The CPT® code modifier 59 is used to identify a distinct procedural service.

Can I get seasonal flu even though I got a flu vaccine this year? Yes. It's possible to get sick with flu even if you have been vaccinated (although you won't know for sure unless you get a flu test).

Payment Allowances and Effective Dates for the 2022-2023 Flu Season: CodeLabeler NameVaccine Name90688Sanofi Pasteur SeqirusFluzone Quadrivalent (2022/2023) Afluria Quadrivalent (2022/2023)90694SeqirusFluad Quadrivalent (2022/2023) (Preservative Free)90756SeqirusFlucelvax Quadrivalent (2022/2023)6 more rows • 12 Sept 2022

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232