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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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