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SERVICE AGREEMENT
This form constitutes a Service Agreement between the above named Church/Parish/Religious Organization (Church) and the Seattle Visiting Nurse Association (SVNA) to sponsor a 2012, on-site, seasonal Flu Immunization Clinic for Church members, church staff and/or guests.
Church agrees to provide an appropriate space for SVNA clinicians to provide immunizations and to assist SVNA in promoting the Flu Immunization Program to Church members and staff.
The Seattle Visiting Nurse Association is a non-profit, tax-exempt 501(c)(3) community based, immunization and wellness services provider. Although we do not require that a Church sponsored Flu Clinic guarantee, assure or otherwise commit to a minimum Flu Clinic participation we do ask, and will appreciate Church support to promote and encourage participation to achieve at least 20 immunizations per clinic.
Seattle Visiting Nurse Association will:
2012 FLU CLINIC REQUEST FORM - CHURCH ORGANIZATION
CHURCH SPONSORED CLINIC INFORMATION
Church Name
Church Address
Clinic Location
City
Zip
Church Contact
Phone
Contact Email
FAX
Estimated Number of Immunizations
PLEASE REVIEW FORM ... WHEN READY TO SEND CLICK SUBMIT BUTTON
If Preferred, Form may be printed and faxed to Seattle Visiting Nurse Association at: 425-361-7162
Preferred Clinic Month
Preferred Day
Preferred Time
Special Requests/Comments
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).
If "OTHER" selected above please identify insurance plan
If requested, bill Church employee insurance plan for flu shot. (Select Plan)
Provide seasonal Flu Shots for Church members and staff for $28.00 per immunization. Cash or check only.
Bill Medicare Part B and most area Medicare Advantage Plans for covered flu shot cost.
Other Payment Arrangement (Please describe)
