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Attachment B Sample Influenza Vaccine Declination Form Facility Name: You have given me the opportunity to be vaccinated with the influenza vaccine at no charge to myself. I have received, read and.

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Z28. 310-Unvaccinated for COVID-19 (Use this code when the patient has not received at least one dose of any COVID-19 vaccine.

Vaccine Declination. Covered Individuals who choose to decline influenza vaccination must complete a Vaccine Declination Letter and submit it to the location vaccine authority on or before December 1, 2022.

Z23 is the ICD-10 code that identifies an encounter for immunization(s). If a vaccine is given within the same visit as other services, eg, preventive health care, the ICD-10 code for that service would be primary, and Z23 would be a secondary ICD-10 code.

For immunization refusal due to another reason, such as the discomfort of injections, ICD-10 code Z28. 21, “Immunization not carried out because of patient refusal.” For immunization refusal by a parent or other caregiver for a child, ICD-10 code Z28. 82, “Immunization not carried out because of caregiver refusal.”

ICD-10 code Z28. 21 for Immunization not carried out because of patient refusal is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

2023 ICD-10-CM Diagnosis Code Z28. 9: Immunization not carried out for unspecified reason.

A legal document that signals an individual's intent to refuse a recommended treatment, e.g. a requirement for vaccination of health care workers against influenza.

Declination form means the form that is signed by and collected from Clients who decline voter registration services. A Client refusing to sign the Voter Registration Form is also a “Declination.”

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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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:
1-877-389-0141
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