Flu Site Billing Info by bvt11437


									              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:


Or contact the Laura Kuperstein, Oregon SafeNet Program Manager, at 503-
416-2604 or laura@211info.org.

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
               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: safenet@211info.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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