2022 Flu Clinic Request Form

Name of Organization

Entity Type

Company Address

City

State

Zip Code

Contact Name

First NameLast Name

Contact Phone

Area CodePhone Number

Contact Email

Health Insurance Plan

Other Health Plan

If "Other" was selected above, please list your health plan.

Please note we are unable to bill the following insurance companies: Cigna, TriCare, out-of-state Blue Cross Blue Shield.

What Percentage of your Workforce do you Expect to be in-office this Fall?

Roughly how many Employees will be Working In-Office?

Preferred Month for Clinic?

Preferred Week Day to hold Clinic?

Parking Validation?

Parking Instructions

Special Requests / Comments

SERVICE AGREEMENT

This form constitutes a Service Agreement between above named Company and VaxPoint LLC d/b/a Seattle Visiting Nurse Association (SVNA) to provide a 2022 seasonal "Flu Immunization Clinic" on-site at your specified location.

SVNA will provide licensed nurses for flu shot administration, administrative support, immunization supplies, and a digital registration link. SVNA will maintain the security and privacy of identifiable health information as required by law.

Company agrees to provide appropriate space for immunization clinic and to assist in promoting the Flu Immunization Program to its employees.

Company efforts to promote and support maximum employee participation will be appreciated.

SVNA does not charge any travel or clinic cancellation fees.

Payment Options

Employee’s insurance plan will be billed. Uninsured employees will be billed by SVNA individually for the flu immunization.Employee’s insurance plan will be billed. The Company agrees to reimburse SVNA for uninsured employee immunizations.The Company will pay out of pocket for all employee’s immunizations, regardless of insurance status. SVNA will invoice the company directly at $50 per immunization.