Listing Your Immunization Event on SafeNet Oregon SafeNet is the statewide, toll free helpline for health and social service information. As you may already know, the Adult Immunization Program partners with Oregon SafeNet each year during flu season to help get information out to the public about available flu clinics. This partnership has made an enormous difference in helping people get their flu shots! Please help us this year by providing the necessary information about your flu clinics to Oregon SafeNet. And, if new clinics are added during the season, please keep SafeNet informed of these changes. The easiest and most efficient way of giving SafeNet the necessary information is by completing a simple, one page form that can be found on the following page or by going to: http://www.oregon.gov/DHS/ph/acd/flu/influenza/shtml Or contact the Laura Kuperstein, Oregon SafeNet Program Manager, at 503- 416-2604 or email@example.com. Finally, feel free to refer callers to Oregon SafeNet for information on other flu clinics in your area or for any other health or social service needs! 1-800-723-3638 (SafeNet) Monday-Friday 8am-8pm www.oregonsafenet.org FAX TO: FROM: Oregon SafeNet Agency: 621 SW Alder, Suite 810 Contact Person: Portland, OR 97205 Address: Client line: 800-723-3638 City, State, Zip Admin line: 503-226-3099 Phone: Fax: 503-499-4302 Fax: Email: firstname.lastname@example.org Email: Ages Served Adults ages 18+ Older children ages 12-18 Younger children 6 mos up to 12 years Flu Site Billing Info Flu shot $______ Pneumococcal Shot $_______ Thimerosal-free vaccine available? Yes No Flu Mist? Yes No Medicare billed? Yes, for flu Yes, for pneumococcal No Do Medicare recipients need to pay money up front? Yes No If yes, how much? $________ Do you bill other insurance?? Yes No If yes, which plans? _____________________________________________________________ Thank you for using Oregon SafeNet as a resource!! Submit detailed flu site info ASAP by fax or electronically (preferred) to email above. Notify Oregon SafeNet ASAP of any changes in schedules or billing information. Notify SafeNet, prior to event or article, when you plan to reference them in any media. Please use the wording, “Oregon SafeNet” when advertising. Flu Shot Sites open to the public Date Hours Name of Site Address Zip Code Your flu clinic information will be shared with the American Lung Association of Oregon and Posted on their website so it can be accessed by the public. Check here if you do not want clinic information put on the American Lung Association website.
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