"Immunization Reporting Form for Nursing Homes" - Arkansas

Immunization Reporting Form for Nursing Homes is a legal document that was released by the Arkansas Department of Health - a government authority operating within Arkansas.

Form Details:

  • Released on July 1, 2021;
  • The latest edition currently provided by the Arkansas Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Department of Health.

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IMMUNIZATION REPORTING FORM for Nursing Homes
ARKANSAS DEPARTMENT OF HEALTH
NHImm (Revised 07/2021)
4815 West Markham St. SLOT # 48
Little Rock, AR 72205-3867
Tel: (501) 537-8969 Fax: (501) 661-2300
Clinic Code for Providers
Nursing Home Clinic Code if ADH administers
Date Vaccine Administered
/
/
Patient should be screened for contraindications prior to receiving any influenza or pneumococcal vaccine.
Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination (immunize.org)
Screening Checklist for Contraindications to Vaccines for Adults (immunize.org)
___________________________
_____________
MI ___
1. Patient Information: Last Name (apellido)
First Name (nombre)
(
Gender
género):
Male
Female
Date of Birth (fecha de nacimiento):
/
/
Asian/Pacific Islander
Race:
Black/African American
Native American/Alaskan Native
White
Other
(raza )
Ethnicity: (origen étnico)
Hispanic
Non-Hispanic
Address:
(dirección) (Omit address and phone number if nursing home resident)
(número de apartamento)
Apt. No.
City
State
Zip Code
(ciudad)
(estado)
(código postal)
Phone Number
(teléfono)
-
-
2. Insurance Status
(Check appropriate box): (estado de seguros, Compruebe la caja apropiada):
(Enter both Medicare Number and Medicaid Number including any other insurance information if applicable)
Medicare Number (
número de asistencia médica)
(
Medicaid
número de seguro de enfermedad)
Private Insurance (name): ________________________________________________________
Insurance ID Number
(Número de identificación de seguro)
Insurance Group Number
(Número de Grupo de Seguros)
(
No Insurance
Ningún Seguro)
3. Release and Assignment
(Publicar y Asignar)
I have read or had explained to me the Vaccine Information Statement (VIS) for the Inactivated Influenza Vaccine and for the Pneumococcal
(PPSV23) Vaccine as applicable and I understand the risks and benefits. To read the current VIS for each vaccine, visit the website
https://www.cdc.gov/vaccines/hcp/vis/current-vis.html.
I give consent to the State/Local Health Department/Nursing Home Facility and its staff for the individual named at the top of this form to be
vaccinated with any of these vaccines.
I hereby acknowledge that I have reviewed a copy of the Privacy Notice from the Arkansas Department of Health.
I understand that information about these vaccines will be included in the Arkansas Department of Health’s Immunization Registry.
To My Insurance Carrier(s):
I authorize the release of any medical information necessary to process my insurance claim(s).
I authorize and request payment of medical benefits directly to the Arkansas Department of Health, if applicable.
I agree that the authorization will cover all medical services rendered until such authorization is revoked by me.
I agree that the photocopy of this form may be used in lieu of the original.
Signature of Patient/Guardian for seasonal flu (Firma):
Date: ______________________________
Signature of Patient/Guardian for Pneumococcal (PPSV23) vaccine (Firma):
Date: _________________
MFG Codes: SEQ = Seqirus, SKB = GlaxoSmithKline,
Site Codes: Right Deltoid = RD, Left Deltoid = LD,
Seasonal Influenza (Preservative Free ≥ 3 years)
PMC = Sanofi, MED = Medimmune, Merck = MSD
Right Arm = RA, Left Arm = RA, Right Leg = RL, Left Leg = LL
Seasonal
Route
Site
Dosage
MFG
Lot Number
Signature /Title of Vaccine
Code
mL.
Code
Administrator
Flu
Vaccine
IM
0.5
Pneumococcal (PPSV23)
Route
Site
Dosage
MFG
Lot Number
Signature /Title of Vaccine
Code
mL.
Code
Administrator
Pneumococcal
Vaccine
IM
0.5
IMMUNIZATION REPORTING FORM for Nursing Homes
ARKANSAS DEPARTMENT OF HEALTH
NHImm (Revised 07/2021)
4815 West Markham St. SLOT # 48
Little Rock, AR 72205-3867
Tel: (501) 537-8969 Fax: (501) 661-2300
Clinic Code for Providers
Nursing Home Clinic Code if ADH administers
Date Vaccine Administered
/
/
Patient should be screened for contraindications prior to receiving any influenza or pneumococcal vaccine.
Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination (immunize.org)
Screening Checklist for Contraindications to Vaccines for Adults (immunize.org)
___________________________
_____________
MI ___
1. Patient Information: Last Name (apellido)
First Name (nombre)
(
Gender
género):
Male
Female
Date of Birth (fecha de nacimiento):
/
/
Asian/Pacific Islander
Race:
Black/African American
Native American/Alaskan Native
White
Other
(raza )
Ethnicity: (origen étnico)
Hispanic
Non-Hispanic
Address:
(dirección) (Omit address and phone number if nursing home resident)
(número de apartamento)
Apt. No.
City
State
Zip Code
(ciudad)
(estado)
(código postal)
Phone Number
(teléfono)
-
-
2. Insurance Status
(Check appropriate box): (estado de seguros, Compruebe la caja apropiada):
(Enter both Medicare Number and Medicaid Number including any other insurance information if applicable)
Medicare Number (
número de asistencia médica)
(
Medicaid
número de seguro de enfermedad)
Private Insurance (name): ________________________________________________________
Insurance ID Number
(Número de identificación de seguro)
Insurance Group Number
(Número de Grupo de Seguros)
(
No Insurance
Ningún Seguro)
3. Release and Assignment
(Publicar y Asignar)
I have read or had explained to me the Vaccine Information Statement (VIS) for the Inactivated Influenza Vaccine and for the Pneumococcal
(PPSV23) Vaccine as applicable and I understand the risks and benefits. To read the current VIS for each vaccine, visit the website
https://www.cdc.gov/vaccines/hcp/vis/current-vis.html.
I give consent to the State/Local Health Department/Nursing Home Facility and its staff for the individual named at the top of this form to be
vaccinated with any of these vaccines.
I hereby acknowledge that I have reviewed a copy of the Privacy Notice from the Arkansas Department of Health.
I understand that information about these vaccines will be included in the Arkansas Department of Health’s Immunization Registry.
To My Insurance Carrier(s):
I authorize the release of any medical information necessary to process my insurance claim(s).
I authorize and request payment of medical benefits directly to the Arkansas Department of Health, if applicable.
I agree that the authorization will cover all medical services rendered until such authorization is revoked by me.
I agree that the photocopy of this form may be used in lieu of the original.
Signature of Patient/Guardian for seasonal flu (Firma):
Date: ______________________________
Signature of Patient/Guardian for Pneumococcal (PPSV23) vaccine (Firma):
Date: _________________
MFG Codes: SEQ = Seqirus, SKB = GlaxoSmithKline,
Site Codes: Right Deltoid = RD, Left Deltoid = LD,
Seasonal Influenza (Preservative Free ≥ 3 years)
PMC = Sanofi, MED = Medimmune, Merck = MSD
Right Arm = RA, Left Arm = RA, Right Leg = RL, Left Leg = LL
Seasonal
Route
Site
Dosage
MFG
Lot Number
Signature /Title of Vaccine
Code
mL.
Code
Administrator
Flu
Vaccine
IM
0.5
Pneumococcal (PPSV23)
Route
Site
Dosage
MFG
Lot Number
Signature /Title of Vaccine
Code
mL.
Code
Administrator
Pneumococcal
Vaccine
IM
0.5