VaccineandAdministration(Injection)ClaimForm ThisclaimformisforreimbursementofcoveredPartDvaccines

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City State Zip

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NameofPhysician

NationalProviderIDNumber:__________________________

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■■C.Mymedicationisnotstocked regularlyatanaccessiblenetwork ormai-ore hrmca ay.l drp.M eiato■■D ymdcinwasdipnesesd fr aemrecomn egnydpreatmn,et prvdrbsdlnoie-aeciicota,upintet sugrfcit tereyal,rohriyooupinsttn.tateteig

■■E.Ireceivedavaccineatmy docosoie(Bsrtffc. eueotr’ includethereceiptfromthe physicianandcompleteVaccine RxInformationsectiononthe bak.c)

■■F.Iwasevacuatedordisplaced frommyresidenceduetoa state-orfederallydeclared tro lh egny.diasse rhaetemrec

ClaimInformation Plaehcataappy.escekllht l

Thisclaimisfor: ■■ Thevaccine ■■ Administration(injection) ofthevaccine

■■ Boththevaccineandthe administration(injection) ofthevaccine

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Rx# Days Date Vaccine Vaccine

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■■ ZO V *STAAX 69300000046 il1Va 1

■■ ZO V *STAAX 69310000464 il1Va 1

■■ ZO V *STAAX 46505887300 1Vail 1

■■ D VECAAC 42121398098 . L05m 1

■■ TTANU IDE STOXO 98021421800 05m. L 1

■■ ENGERIX-B 58160082111 1mL 1

■■ ENGERIX-B 58160082146 1mL 1

■■ M-M-RIIVACCINE 00006468100 1mL 1

■■ TWINRIX 58160081546 1mL 1

■■ HAVRIX 58160082611 1mL 1

■■ HAVRIX 58160082646 1mL 1

■■ RECOMBIVAXHB 00006499500 1mL 1

■■ VAQTA 00006484100 1mL 1

■■VAR AXV INIV ACC E 00004268700 1Vail 1

■■ GARDAI †SL 00004460500 05mL. 1

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