Influenza Vaccine 2008 - Springfield, MA
Seasonal Influenza Vaccine 2010-2011
Adult Vaccine Administration Record
MAHP/Masspro Reimbursement Program
Information about the person to receive vaccine (please print):
|Name: (Last, First, MI) |Birth date: |Age: |Sex: |
| | | |M F |
|Street address: |
|City: |State: |Zip: |Phone: |
| | | |( ) |
If you have a membership card from one of these plans, write in the card number:
|AARP MedicareComplete | |
|(SecureHorizons/UnitedHealthcare) |# |
|Evercare Plan MP/PPO | |
|(UnitedHealthCare) | |
|Evercare Senior Care Options | |
|(UnitedHealthcare) |# |
|Fallon Senior Plan | |
|(Fallon Community Health Plan) |#888 |
|First Seniority Freedom | |
|(Harvard Pilgrim Health Care) |# 9 _ _ _ _ -- _ _ _ _ _ _ _ _ _ -- _ _ |
|HNE Medicare Advantage Plans | |
|(Health New England) |#9 |
|Medicare HMO Blue | |
|(Blue Cross Blue Shield of MA) |# XXC |
|Medicare PPO Blue | |
|(Blue Cross Blue Shield of MA) |# XXU |
|NaviCare | |
|(Fallon Community Health Plan) |# |
| | |
|Senior Whole Health |# 1 _ _ _ _ _ |
|Tufts Health Plan Medicare Preferred | |
|(Tufts Health Plan) |# S _ _ _ _ _ _ _ _ |
| | |
|Medicare Card Number |# |
I give permission to bill my insurance company.
(Signature of person to receive vaccine or that person’s guardian)
X Date
For Clinic/Office Use:
Vaccine name: Date vaccine administered:
Injection site: Date VIS given: Date on VIS:
Vaccine manufacturer: Vaccine lot number:
Name and title of vaccine administrator:
Clinic/office address:
................
................
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