Flu Vaccinations Available at Your Child s School! Carson City School District Group Health Members see the chart below for clinic dates:

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1 COMMUNIT Y Immunity We vaccinate because......our kids are our world! Flu Vaccinations Available at Your Child s School! Carson City School District Group Health Members see the chart below for clinic dates: Bordewich-Bray 9/15/15 Carson High 9/17/15 9/18/15 Carson Middle Eagle Valley MS Early Childhood 9/18/15 9/16/15 9/11/15 Empire ES Fremont ES Fritsch ES Mark Twain Seeliger ES 9/16/15 9/14/15 9/15/15 9/17/15 9/14/15 No one will be turned away! We bill Medicaid, Medicare and most private insurances! For additional information and a current list of the insurances that we bill, please visit our website: For more information about our community outreach clinics, please call (775) or

2 Annual Influenza Vaccination Parent Letter Dear Parent: Carson City Health and Human Services (CCHHS) is working with your child s school to offer your child seasonal flu vaccination. There will be a team of CCHHS licensed nurses at your child s school from September 14 18, 2015, to administer the flu vaccine. The vaccination is a safe and preventative health action that benefits all age groups to protect against influenza illness. This year the vaccine will protect against four flu viruses. Two kinds of flu vaccines are available: Inactivated "flu shot" containing killed virus that is given with a needle, usually in the arm. The flu shot is approved and recommended for people 6 months of age and older. Live nasal spray flu vaccine a vaccine made with live, weakened viruses (LAIV) that do not cause the flu. LAIV is approved for use in people 2 years to 49 years of age who are not pregnant and have no chronic medical conditions, including asthma. The Influenza Vaccine Information Statement will be given to your child on the day of vaccination or can be obtained from the CCHHS website, where you can also access more information: Attached to this letter is a vaccination consent form. In order for your child to receive a vaccine please: Complete and sign Consent Form and send yellow consent form back to the child s school / teacher by September 11, Clearly mark on yellow Consent Form which vaccine you want your child to have. Complete the Insurance Information on the yellow Consent Form for Medicaid, Nevada Check Up and the private plans we bill. (Attach a copy of the front & back of your insurance card) Provide payment in an envelope, if appropriate. Read the Vaccine Information Sheets. CCHHS will bill the following insurance companies (no payment necessary): Aetna Amerigroup Anthem Blue Cross / Blue Shield CDS Cigna Coventry Health Care Gov t Employee Health Assn. (GEHA) Health Plan of Nevada HealthSCOPE Hometown Health (HHP) Humana Medicaid Nevada Checkup MultiPlan Nevada Preferred Provider PEBP Prominence Health Plans TRICARE / TriWest Universal Health Vaccine Administration fee at time of service is $20 if: your child s insurance does not cover vaccinations, your child does NOT have insurance, your child is Native American / Alaska Native, or your child s insurance company is NOT listed above. Please refer to the schedule below for when a CCHHS team will be at your child s school: Bordewich-Bray ES Carson High Carson Middle Eagle Valley MS Early Childhood 9/15/15 9/17/15 9/18/15 9/18/15 9/16/15 9/11/15 Empire ES Fremont ES Fritsch ES Mark Twain ES Seeliger ES 9/16/15 9/14/15 9/15/15 9/17/15 9/14/15 Children younger than 9 years of age on the day the vaccine is administered, he/she will need 2 flu doses if: they are receiving influenza vaccine for the first time, or have not received 2 doses of flu vaccines since July Should your child need a second dose, Thursday is immunization day at Carson City Health & Human Services (located at: 900 East Long St., Carson City, NV 89706) from 8:30 a.m. to 4:30 p.m., or you may contact your healthcare provider. If you have any questions you may contact me at (775) Sincerely, Karen Allen, RN Carson City Health and Human Services Carson City Health & Human Services 900 East Long Street Carson City, Nevada Phone (775) Fax (775) CCHHS SLV 8/15

3 Annual Influenza Vaccination Parent Letter Estimado(s) Padre(s): Carson City Health and Human Services (CCHHS) esta trabajando con la escuela de su hijo para ofrecerle la vacuna de la influenza temporal. Un equipo de Enfermeras Registradas de CCHHS estará en la escuela de su hijo(a) para darles la vacuna contra la gripa en la semana de Septiembre14-18, La vacunación contra la influenza temporal es una acción preventiva, segura y saludable que beneficia a los grupos de todas las edades para protegerlos contra la enfermedad de la influenza. Este año la vacuna protegerá contra cuatro virus de la influenza. Existen dos tipos de vacunas antigripales que están disponibles: Desactivada "Inyectable flu shot" Que contiene virus muerto y es dado a través de una inyección, usualmente en el brazo. La vacuna contra la gripa está aprobada y recomendada para personas mayores de 6 meses de edad. Influenza Viva Atenuada Aerosol Nasal Una vacuna hecha con virus vivo debilitado (LAIV) que no causa la gripa. LAIV esta aprobada para ser usada en personas de 2 años a 49 años de edad que no estén embarazadas y que no tengan condiciones crónicas, incluyendo asma. La información sobre la vacuna será entregada a su hijo (a) el día de vacunación o también pueden obtenerla en la página de Internet de CCHHS Programa de vacunación escolar en: Junto con esta carta hay un cuestionario de vacunación. Para que su hijo reciba la vacuna, por favor haga los siguiente: Complete y firme el formulario de Consentimiento y mande le consentimiento de regreso a la escuela de su hijo/a o a la profesora Septiembre 11, Claramente marque cual vacuna(s) quiere que su hijo/a reciba. Complete la información sobre el seguro médico en el consentimiento amarillo de Medicaid, Nevada Check Up y los planes privados que facturamos. (Adjunte una copia del frente y el reverso de la tarjeta de seguro). Proporcione el pago en el sobre, si es apropiado. Lea la hoja de información sobre la vacuna. CCHHS puede mandar a cobrar a las siguientes compañías de seguro médico (Si mandamos a cobrar estos seguros médicos, el pago no será necesario): Aetna Amerigroup Anthem Blue Cross / Blue Shield CDS Cigna Coventry Health Care Gov t Employee Health Assn. (GEHA) Health Plan of Nevada HealthSCOPE Hometown Health (HHP) Humana Medicaid Nevada Checkup MultiPlan Nevada Preferred Provider PEBP Prominence Health Plans TRICARE / TriWest Universal Health Costo de Administración de la vacuna a la hora del servicio es $20 si: El seguro médico de su hijo no cubre las vacunas, Su hijo NO tiene seguro médico Su hijo es Nativo Americano / Nativo de Alaska, o El seguro médico de su hijo NO está en la lista anterior. Por favor revise el cuadro de abajo para que tenga conocimiento de cuando el equipo de enfermeras estará en la escuela de su hijo(a): Bordewich-Bray ES Carson High Carson Middle Eagle Valley MS Early Childhood 9/15/15 9/17/15 9/18/15 9/18/15 9/16/15 9/11/15 Empire ES Fremont ES Fritsch ES Mark Twain ES Seeliger ES 9/16/15 9/14/15 9/15/15 9/17/15 9/14/15 Si su hijo es menor de 9 años el día que la vacuna será administrada; él/ella va a necesitar dos dosis de la vacuna; Solamente si están recibiendo la vacuna contra la gripa por primera vez, o no han recibido 2 dosis de la vacuna contra la gripa desde Julio Si su hijo (a) va a necesitar la segunda dosis, Cada Jueves es día de inmunización en CCHHS (localizado en 900 East Long St., Carson City, NV 89706) de 8:30 a.m. a 4:30 p.m. o usted puede contactar a su proveedor de salud. Si usted tiene alguna pregunta, por favor llame al (775) Sinceramente, Karen Allen, RN Carson City Health and Human Services Carson City Health & Human Services 900 East Long Street Carson City, Nevada Phone (775) Fax (775) CCHHS SLV 8/15

4 Influenza Immunization Questionnaire / Consent Form PATIENT Name Phone ( ) Mailing Address City/State/Zip Code Birth Date / / Age Today Gender F M History of Chicken Pox Yes No Month Day Year Race (Check one box only) Ethnicity (Check one box only) Patient s Social Security # Caucasian Black/African American Asian American Indian/Alaskan Native Pacific Islander Insurance Status (Check one box only) Hispanic/Latino Not Hispanic/Latino - - Required to access your immunization records online * Please include a copy of the front and back of insurance card Insured: Insurance Company: Insurance/ID #: Group #: Policy Holder Name: Birth Date: / / Medicaid / NV Check Up #: Medicare #: Policy Holder Relationship to Patient: Uninsured / No insurance Insured, but vaccines are not a covered benefit * Please include $20 for administration fee or whatever you can afford * Please include $20 for administration fee or whatever you can afford Please answer the following questions about THE PERSON to be vaccinated 1. Sick today? YES NO 2. Allergic to eggs, latex, food, medication, vaccine ingredients? If yes, list: YES NO 3. Had a serious reaction to or fainted with previous immunization? YES NO 4. Had Guillain-Barre syndrome in the past? YES NO 5. Had seizure or other nervous system problem? YES NO 6. Have cancer, AIDS or other immune system problems? YES NO 7. Taken cortisone, prednisone or any steroids, anti-cancer drugs, or radiation in the last 3 months? YES NO 8. Received antiviral drugs in the last 3 months? YES NO 9. Received any other immunizations, including influenza, in the last month? If yes, list: YES NO 10. Received a blood or blood product transfusion, or been given immune (gamma) globulin in the last year? YES NO 11. Have long-term medical problems: diabetes, heart, kidney or lung disease, asthma, wheezing or blood disorders? YES NO 12. Pregnant or plan to become pregnant in the next month? YES NO 13. Been vaccinated against influenza (flu) in the past? YES NO 14. Vaccine to be received today: Either Nasal or Shot Nasal Shot I have received and understand the vaccine information sheet(s) for the immunization(s) to be administered. I authorize CCHHS to enter this information into the Nevada Immunization Registry, unless otherwise specified. I understand the CCHHS Notice of Privacy is available at gethealthycarsoncity.org/immunizations. I hereby authorize & direct payment of medical benefits to CCHHS for any services provided to me or my dependents. If my carrier deems these services non-payable, I agree that I am financially responsible for any outstanding balances. Client/Parent/Guardian Signature Parent/Guardian signature required if under 18 years old Client/Parent/Guardian Print Name Date / / CLINIC USE ONLY DO NOT WRITE BELOW THIS LINE Circle Location Below RD LD IM Nasal Administered by: Date: / / Clinic Location: (Write Legibly) First Initial Last Name Credential Amount $: Cash Check CC $ Reconciliation: WebIZ: ecw/scan: ecw Charting: June 2015

5 Cuestionario de Inmunización NOMBRE del Paciente Teléfono # ( ) Dirección Cuidad/Estad/Código Postal Fecha de Nacimiento Mes /Día / Año Edad de Hoy Sexo F M Le ha dado Varicela Yes No Raza Etnicidad Número de Seguro Social # de paciente Caucásico Afro-Americano Asiático Americano Nativo Isleño del Pacifico Estafo de Cobertura Medico (Marque sólo una casilla) Hispano/Latino No Hispano/No Latino - - Requerido solamente si quiere acceso al expediente en línea de las vacunas de su Niño(a) * Por favor, incluya una copia del frente y reverso de la tarjeta de seguro Seguro Médico Privado: Nombre de la compañía de seguro Médico: Número de identificación de seguro Médico #: Numero de Grupo: Nombre de la Persona Primaria: Fecha de Nacimiento: / / Medicaid / NV Check Up #: Medicare #: Relación con la Persona Primaria: No tiene seguro Médico * Por favor incluya $20 por cuota de administración o lo que usted pueda pagar Tiene seguro Médico, pero no cubre las vacunas * Por favor incluya $20 por cuota de administración o lo que usted pueda pagar Favor de contestar las siguientes preguntas sobre LA PERSONA que se va a vacunar 1. Esta enfermo hoy? Sí NO 2. Es alérgico a los huevos, medicamento, látex o algún componente de vacunas? Anote sus alergias: Sí NO 3. Ha tenido alguna reacción seria o se a desmayado con alguna vacuna en el pasado? Sí NO 4. Ha tenido el síndrome de Guillain-Barre? Sí NO 5. Ha tenido convulsiones o algún problema del sistema nervioso? Sí NO 6. Tiene cáncer, SIDA u otros problemas del sistema Inmunológico? Sí NO 7. Ha tomado cortisona, prednisone o algún esteroide, medicina anticaner o radiación en los últimos 3 meses? Sí NO 8. Ha recibido alguna medicina antiviral en los últimos 3 meses? Sí NO 9. Ha recibido otras vacunas en los últimos 28 días, como la de influenza (gripe)? Sí NO 10. Ha recibido una transfusión de sangre o productos de sangre, le han dado gamma inmune (gama) Globulina en Sí NO el último año? 11. Tiene problemas a largo plazo de diabetes, enfermedad Cardiaca, enfermedad pulmonar, enfermedad renal, Sí NO respira con silbido o asma, Anemia, o algún desorden sanguíneo? 12. La persona que se va a vacunar hoy está embarazada o planea quedar embarazada? Sí NO 13. Ha sido vacunado(a) / a contra la influenza en el pasado? Sí NO 14. Mi hijo (a) puede recibir la vacuna antigripal Ya sea la Nasal o Inyectable Nasal Inyectable He recibido y entiendo la hoja de información sobre la vacuna que será administrada. Autorizo a CCHHS a guardar esta información en el registro de Inmunizaciones de Nevada, a menos que yo especifique lo contrario. Entiendo que el Aviso de privacidad de CCHHS está disponible en gethealthycarsoncity.org/immunizations. Por este medio autorizo el pago directo a CCHHS de los servicios médicos prestados a mí o a mis dependientes. Si mi seguro médico no paga o cubre los servicios, estoy de acuerdo que soy financieramente responsable de los saldos pendientes. Firma del Cliente/Padre/Guardián Se requiere la firma de los padres/guardián para menores de 18 años Escriba claro el nombre del Cliente/Padre/Guardián CLINIC USE ONLY POR FAVOR NO ESCRIBA DEBAJO DE LA LINEA Fecha / / Circle Location Below RD LD IM Nasal Administered by: Date: / / Clinic Location: (Write Legibly) First Initial Last Name Credential Amount $: Cash Check CC $ Reconciliation: WebIZ: ecw/scan: ecw Charting: June 2015

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