2020 - 2021 Flu Insurance Information Form
The completion of this form is necessary for every vaccine recipient. If no insurance information is
available, please fill out as much as possible using existing information.
Information about the person to receive vaccine (please print): *Required Fields
Name: (Last, First, MI)* Date of birth: *
_____ ____ _____
Month Day Year
Age* Sex: (Check)*
Male
Female
Street Address:*
City:* State: * Zip:* Phone:*
Insurance Information: Include the whole member ID number and any letters that are part of that number
Name of Insurance Company:* Member ID Number:* Group ID Number: (if available)
MEDICARE Number Is Medicare Primary?
YES NO
Is Subscriber Employed?
YES NO
If person getting vaccinated is not the subscriber, please complete the following:
Subscriber’s Name: (Last, First, MI)* Subscriber’s Date of Birth: *
_____ ____ _____
Sex: (Check)*
Ma
le Female
Subscriber’s Street Address:* (If different from address above)
City:* State:* Zip: * Phone:*
Patient Relationship to Subscriber: (Check)* Spouse Child Other
I give permission to receive the vaccine and for my insurance company to be billed.
X ______
Date: ________________
(Signature of patient, parent or legal guardian)
*************************************************************************************************************************
For children 18 years of age and younger:
Is Vaccine for Children (VFC) Program eligible:
Is enrolled in Medicaid (includes MassHealth and HMOs, etc.,
if enrolled through Medicaid)
Does not have health insurance
Is American Indian (Native American) or Alaska Native
Is not VFC-eligible:
Has health insurance and is not American Indian
(Native American) or Alaska Native
For Clinic/Office Use Only:
Provider Name: Foxborough Public Safety MDPH Provider PIN# 42090
Provider Address: 8 Chestnut Street, Foxborough, MA 02035
Vax
Type
Vax
Mfgr
Dose Prese
rv
Free
Injection
Route
(Circle)
Vaccine
Administrator
IIV4
IIV4
IIV4-HD
Sanofi
Se
quiris
.5mL
.5mL
No
Yes
IM
R Arm
L Arm
State
Supplied
(Circle)
Lot No Exp Date Date
On
VIS
Date VIS
Given
Yes
No
Town of Foxborough Public Health
D
