Form Dhec 1209 PDF Details

Form DHEC 1209 is a medical form issued by the South Carolina Department of Health and Environmental Control (DHEC) that enables healthcare providers to submit requests for various services, such as laboratory tests. As an important document used in day-to-day operations, it helps ensure health care facilities receive the necessary lab work rapidly and efficiently. Whether you are an employer wishing to provide laboratory services or a healthcare provider submitted requests through Form DHEC 1209, understanding this document's intent will allow you to make informed decisions regarding requesting and providing necessary testing. In this blog post, we’ll take a closer look at what the DHEC 1209 form is intended for and how it affects both employers and healthcare providers.

QuestionAnswer
Form NameForm Dhec 1209
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesD 1209 dhec expiration form

Form Preview Example

SOUTH CAROLINA

VACCINE WASTAGE AND RETURN FORM

Wastage and return of vaccine requires pre-authorization by DHEC Division of Immunizations. Call DHEC Division of

Immunizations at 800-277-4687 or email to immunize@dhec.sc.gov before wastage/return of vaccine.

 

Date:

 

 

 

 

 

Need Shipping Label?

Yes No

 

PIN Number:

 

 

 

 

 

# of Labels Requested: ______________

 

Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

Fax:

 

 

 

 

 

 

Contact Person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Returned to

Reason

 

Program

NDC

 

Vaccine

 

Doses

Mfg

 

Lot #

Expiration

 

McKesson

Code*

 

 

Type

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*REASON CODES:

 

 

 

EXPLANATION FOR WASTAGE

 

 

 

 

2 – Recall

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 – Spoilage (Contaminated)

 

 

 

 

 

 

 

 

 

 

 

 

 

4 – Expiration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5 – Lost/damaged/spoiled in transit

6 – Failure to store properly upon receipt

7A – Storage unit too warm

7B – Storage unit too cold

7C – Mechanical failure

7D – Natural disaster/power outage

11 – Lost or unaccounted for in inventory (missing doses) 12A – Dropped/broken vial

12B – Drawn-up but not administered

12C – Inappropriate light exposure

12D – Other (Explain)

For DHEC Use Only:

Cost of vaccine

Shipping label requested:

DHEC 1209 (3/2014) SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

South Carolina

Vaccine Wastage and Return Form

Instructions for Completing

Purpose:

The purpose of the Vaccine Wastage and Return Form is to record the wastage and/or return of vaccine.

Wastage/ Return of vaccine requires pre-authorization by the DHEC Immunization Division. Contact DHEC Immunization Division by phone (1-800- 27-SHOTS or 803-898-0460) or email (immunize@dhec.sc.gov) before wastage/return of vaccine and completion of this form.

Item-By-Item Instructions:

1.Provider will enter identifying information about the provider’s office from which the vaccine is wasted/ returned. All information is required.

2.Provider will enter information for each vaccine being wasted/ returned including Reason Code, Program Type (for example VFC or State), NDC, Vaccine Name, Doses, Manufacturer (Mfg), Lot Number and Expiration Date.

3.If provider is directed by DHEC Immunization Division to return vaccine to McKesson (CDC’s Central Distributor) for excise tax, place a check in the “Returned to McKesson” column.

4.Provider will indicate if a shipping label is needed for return of the vaccine to McKesson and how many labels the provider is requesting. Vaccine is to be returned to McKesson within six months of the expiration date.

5.Provider must provide a written explanation for wastage in space provided.

Office Mechanics and Filing:

1.Provider must fax the completed form to DHEC Immunization Division (803-898-0318).

2.Form Retention:

-VFC & STATE Vaccine providers: retain the original form for (3) three years as required by the Federal Immunization Program.

-DHEC Immunization Program: retain providers' copies for (3) three years as required by the Federal Immunization Program.

-Contracting Parties under a DHEC Memorandum of Agreement (MOA) for Adult Vaccines: Both Provider and DHEC must retain the original/copy for (6) six years.

3.If the provider is directed to return vaccine to McKesson, a copy of the completed form must be sent with the vaccine to McKesson.

DHEC 1209 (3/2014) SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

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