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Physician Flu Vaccine Request Form.pdf


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									Physician Flu Vaccine Request Form
Blue Cross and Blue Shield of North Carolina (BCBSNC) will provide flu vaccine
to participating physicians after November 15, 2006 in the event the CDC has not
announced a vaccine shortage. The primary purpose of this service is to provide
vaccine to those physician offices that have already ordered the vaccine but have
experienced a delay in receiving it. As such, the following criteria apply:

   1) a supply of flu vaccine must already have been ordered by the physician’s
      practice from a manufacturer,

   2) physicians cannot cancel their original vaccine order, and

   3) physicians cannot use this service to add to their original order.

Please provide the following information:

Physician Name:_____________________________________________

Practice Name: _____________________________________________

Provider ID #:_______________________________________________

Phone #:___________________________________________________

Address: __________________________________________________


Quantity of vaccine requested:__________

Physician signature:___________________________________________

Please fax your order form to the attention of Cheryl Allen at 919-765-7291.

Vaccine orders will be sent within 3 business days of receipt of order.

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