The Texas Department of State Health Services presents the EC-87 form as a crucial document designed to facilitate informed consent for the Live, Intranasal Influenza Vaccine, as part of the 2013-2014 campaign. This form stands as an addendum to the Vaccine Information Statement (VIS), ensuring that individuals or their legal guardians are fully aware of the key aspects concerning the vaccine before administration. The document meticulously outlines the necessities such as acknowledging the receipt or the offer of the VIS, understanding both the benefits and risks associated with the vaccine, the rights to ask questions about the vaccine, and the legal authorization for the vaccine's administration to the named individual. Additionally, it incorporates a section for the release of medical information necessary for claim processing and explicit consent for the government benefits payment to the administering party. The form also emphasizes the importance of privacy, aligning with both state and federal regulations by informing recipients about their rights to access, review, and request corrections to collected information, alongside ensuring compliance through the prohibition of unauthorized alterations. By signing this form, the individual or the authorized guardian not only consents to the vaccine but also attests to having received a copy of the immunization provider’s HIPAA Privacy Notice, further solidifying the form’s role in safeguarding patient rights and enhancing transparency in the healthcare decision-making process.
| Question | Answer |
|---|---|
| Form Name | Texas Form Ec 87 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | 2013, HIPAA, dshs, VIS |
Texas Department of State Health Services
Addendum to
Vaccine Information Statement
1.I agree that the person named below will get the vaccine checked below.
2.I received or was offered a copy of the Vaccine Information Statement (VIS) for the vaccine listed above.
3.I know the risks of the disease this vaccine prevents.
4.I know the beneits and risks of the vaccine.
5.I have had a chance to ask questions about the disease the vaccine prevents, the vaccine, and how the vaccine is given.
6.I know that the person named below will have the vaccine put in his/her body to prevent the disease this vaccine prevents.
7.I am an adult who can legally consent for the person named below to get the vaccine. I freely and voluntarily give my signed permission for this vaccine.
Vaccine to be given:
Live, Intranasal Inluenza Vaccine
*STATEMENT: I authorize the release of any medical or other information necessary to process the claim. I also request payment of government beneits to the party who accepts assignment.
Provider Identiication Number: _____________________________________________________
Medicare Health Insurance Claim Number: ____________________________________________
Information about person to receive vaccine (Please print)
Name: Last |
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Middle Initial |
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Birthdate |
Sex |
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(circle one) |
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F |
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Address: Street |
City |
County |
State |
Zip |
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TX
Signature of person to receive vaccine or person authorized to make the request (parent or guardian):
x
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Date |
x |
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Witness |
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Date |
For Clinic/Ofice Use
Clinic/Ofice Address:
Date Vaccine Administered:
Vaccine Manufacturer:
Vaccine Lot Number:
Site of Injection:
Signature of Vaccine Administrator:
Title of Vaccine Administrator:
PRIVACY NOTIFICATION - With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect.
See http://www.dshs.state.tx.us for more information on Privacy Notiication. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
Privacy Notice: I acknowledge that I have received a copy of my immunization provider’s HIPAA Privacy Notice.
Notice: Alterations or changes to this publication is prohibited without the express written consent of the Texas Department of State Health Services, Immunization Branch.
Instructions: File this consent statement in the patient’s chart.
Texas Department of State Health Services
CDC Interim VIS Revision (07/26/13)