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RETIREMENT AND ASSISTED LIVING COMMUNITY SERVICE AGREEMENT
This form constitutes a Service Agreement between above named Assisted Living Community and Seattle Visiting Nurse Association (SVNA) to sponsor a 2012 on-site, seasonal Flu Immunization Clinic(s).
The Seattle Visiting Nurse Association will:
The Seattle Visiting Nurse Association is a non-profit, tax-exempt 501(c)(3) community based, immunization and wellness services provider.
The SVNA does not require that the Retirement Community and/or Assisted Living Facility sponsored Flu Clinic provide SVNA a guaranteed minimum number of attendees at a scheduled flu clinic or otherwise commit to a minimum Flu Clinic participation. We do ask, however, that the property management staff support our efforts to promote and encourage resident participation.
PLEASE REVIEW FORM ... WHEN READY TO SEND CLICK SUBMIT BUTTON
2012 FLU CLINIC REQUEST FORM - ASSISTED LIVING COMMUNITY
ASSISTED LIVING COMMUNITY INFORMATION
Property Name
Clinic Location (Conference Room/Suite, etc.)
Administrative Contact
Phone
Contact Email Address
FAX
Estimated Number of Individuals to Receive Immunizations
Preferred Clinic Month
Preferred Day
Special Requests/Comments
Thank you for chosing the Seattle Visiting Nurse Association for your Flu Immunization Program. We appreciate your support.
Preferred Time
Property Address
City
Zip
Use qualified, licensed, RN and administrative support staff to cover all clinic administration requirements.
Protect and maintain the security and privacy of identifiable health information as required by law.
Provide vaccine and all immunization supplies.
Provide vaccine management to include removal of medical waste (needles,syringes, used supplies and packaging).
Other Payment Arrangement (Please describe)
If requested, bill company employees health insurance plan. (Please select plan).
Provide seasonal Flu Shots, if requested, for property employees for $28.00 per immunization.
Bill Medicare Part B or Medicare Advantage Plans for beneficary/enrollee flu immunizations.
If "OTHER" selected please identify insurance company:
