Are you looking to start a business in the great state of Texas? Filing for a Taxpayer Identification Number with the Texas Comptroller's Office is an essential step. To get started, download form EC-87: Application for Nonprofit Organization Tax Exemption Certificate and complete all applicable sections. By following this guide, you'll have all the information you need to make sure your application is accurate and submitted within the required timeframe!
| 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 |
First |
Middle Initial |
|
Birthdate |
Sex |
|
|
|
|
|
(mm/dd/yy) |
(circle one) |
|
|
|
|
|
|
|
|
|
|
|
|
|
M |
F |
|
|
|
|
|
|
|
Address: Street |
City |
County |
State |
Zip |
||
TX
Signature of person to receive vaccine or person authorized to make the request (parent or guardian):
x
|
|
|
Date |
x |
|
|
|
|
Witness |
|
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)