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SCHOOL MEDICATION PRESCRIBER/PARENT AUTHORIZATION FORM

Medication Prescriber/Parent Authorization Form

This form MUST be filled out by your doctor before any prescription medication can be given to your children at school. Any changes in dosage or time given require new authorization forms from the doctor. We also require written permission from parents/guardians for over the counter medications. Please read the second page of the form for guidelines regarding prescription medications. 

 

Flu Vaccines for Students!

There will be two opportunities for students to receive the flu vaccine at school again this year. Listed below is all the information you need to know for each vaccine program, so that you can get your child vaccinated at school.

 

PEEHIP Flu Vaccine Program - for parents with BCBS PEEHIP insurance

The Public Education Employees' Health Insurance Program (PEEHIP), in cooperation with the Alabama Department of Public Health (ADPH) Wellness Program, will be offering influenza vaccine in our schools this fall according to the schedule below for children who are covered under Blue Cross Blue Shield (BC/BS) PEEHIP. These dates listed below are only for children of PEEHIP members with an insurance policy number starting with the letters EDU. For children not covered under BC/BS PEEHIP, influenza vaccine will be administered by a separate company through the "Teach Flu a Lesson" program which will be explained in the next section.

There are two different types of influenza vaccine. You will have the option of choosing either an intranasal or an injectable vaccine for your child if he or she meets the criteria specified on the Influenza Vaccine Administration Form. There will be no charge for the vaccine.

The following three items are attached. The form marked with an asterisk (*) must be completed, signed by the parent, and returned to your child's school nurse no later than 2 weeks prior to the vaccination date. The two vaccine statements are for your information.

 

PEEHIP FORMS

*Influenza Vaccine Administration Form/Consent Form for Dependents/(click the form name to view/print)

This required form contains contact information and asks questions about your child's health status and history. Parents must select whether they wish their child to receive the nasal spray or the vaccine through injection. It also contains the child's name, address, gender, race, date of birth, and insurance policy information. It gives permission for your child to receive the vaccine and authorizes insurance payment. Individuals will not be charged an administration fee in school-based clinics. The form notes receipt of privacy rights and acknowledges a parent has had the opportunity to discuss the immunization with the provider.

 

Vaccine Information for Flu Mist; Vaccine Information for Injection -These are for your information. Click the title to view.

No student will be vaccinated without signed consent. Complete the Influenza Vaccine Administration Form and turn it in to your child's school nurse. If you have any questions or concerns, please feel free to call your school nurse.

 

 

Teach Flu A Lesson Vaccine Program - for students with other insurance or no insurance

HNH Immunizations Inc. is an Alabama based Vaccine for Children Provider that, along with the Family Health Clinic of Union Springs and the support of Alabama based schools of nursing, will be offering the pain-free FluMist® Quadrivalent vaccine for our students with no deductibles or out of pocket expenses. Medicaid, BCBS, ALL Kids, and other private insurance companies will be billed. Students with no insurance will be provided their flu vaccine at no cost, If you prefer an IIV (shot) please contact 1-205-609-0268, and IIV forms and Vaccine while supplies last. Information Statements will be sent to you for completion. We are prohibited from vaccinating PEEHIP members. Please see the information below regarding PEEHIP flu vaccine dates and procedures.

There are two forms regarding this vaccine program. The form marked with an asterisk (*) must be completed, signed by the parent, and returned to your child's school nurse no later than 2 weeks prior to the vaccination date. The vaccine statement is for your information.

 

*Teach Flu A Lesson Vaccine Consent Form

This required form contains contact information and asks questions about your child's health status and history. It gives permission for your child to receive the flu mist vaccine and authorizes insurance payment. No student will be vaccinated without signed consent. If you have any questions or concerns, please feel free to call your school nurse.

 

Vaccine Information for Flu Mist -This is for your information.

 

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