In-Home Vaccinations Home Visiting Step 1 of 6 - Event 16% Please complete each section and submit the form.Referring Agency(Required)Select AgencyAging and In Home ServicesAWSBenchmark- HomePointeEasterseals NE IndianaHealthier Moms and BabiesIRISIndiana Department of Child ServicesJourney Beside MothersOtherPlease tell us how you heard about our home visiting program. Child’s Information:Patient Name(Required) First Middle Inital Last Patient Date of birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required)Select OneFemaleMaleNon-BinaryI prefer not to sayHome Address(Required)City(Required)State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip(Required)Race(Required)Please Select OneWhiteAfrican AmericanAsianAmerican IndianNatl. Hawaiian, Pac IslAlaskan NativeOtherEthnicity(Required)Please Select OneHispanic/LatinoNot Hispanic/LatinoDeclined to answerLanguage(Required)Please Select OneEnglishSpanishBurmeseOtherPrimary Care Provider(Required)Is the patient disabled?(Required) Yes No Prefer not to say Does the patient have any of the following:(Required) ADHD Autism or ASD Anxiety or Depression Hearing loss/Deafness Learning or intellectual impairment Mental Health Diagnoses Neurological disorder (Epilepsy, MS, Muscular Dystrophy) ODD Physical impairment in one or more limb Speech or language difficulties Vision loss Other Contact Information:Parent/Guardian Name(Required)First NameMiddle InitialLast Name Add RemoveMobile Phone Number(Required)Email Address(Required) Number of People in Household(Required)Please Select One12345678910+Choose not to answerCurrent Household Income(Required)Please Select OneBelow $11,800$11,881-$24,300$24,301-$36,450$36,451-$48,600$48,601-$60,750$60,751-$72,900Over $72,901Decline to Answer Required Health Insurance Information:Select One (Patient's insurance status)(Required) Private Insurance Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise) No Insurance: I certify that the patient is not covered by any health insurance. Medicaid Insurance Provider(Required)Select Medicaid InsuranceAnthem BCBSCareSource-INManaged Health Services-MHSMDWiseOtherPrivate Insurance Company(Required)Private Insurance CompanyAetnaAnthem BCBSCareSourceManaged Health Services-MHS AmbetterCignaMDWiseParkview Signature Care - Signature CarePHP of Northern IndianaUnited HealthcareThree Rivers PreferredLutheran PreferredOther (Enter Below)Other Insurance Company(Required)Member ID(Required)Group #(Required)Policy HolderName(Required) First Middle Initial Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer(Required)Relationship to Patient(Required)Select OneSelfSpouseChildOtherGrandparentGrandchildNephew or NieceFoster ChildWardStepson or StepdaughterEmployeeHandicapped DependentSponsored DependentDependent of a Minor DependentSignificant OtherMotherFatherEmancipated MinorLife PartnerUpload Insurance Card Image (Front)(Required)Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.Upload Insurance Card Image (Back)(Required)Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB. Medical Information:Please select Yes or No for all questions. Answers are for the person getting the vaccine.Is the patient allergic to a vaccine component or latex (ex. gentamicin, alginine, gelatin, or MSG)? (if yes, please note)(Required) Yes No List vaccine component allergies(Required) Add RemoveHas the patient had a serious reaction to a vaccine in the past?(Required) Yes No Describe the serious reaction:(Required)Is the patient pregnant or is there a chance they could become pregnant within a month of being vaccinated?(Required) Yes No Not Applicable Is someone in the patient's home immunocompromised or requires a protective environment?(Required) Yes No Does the patient have any of the following: (mark all that apply)(Required) Chronic Heart Disease Diagnosed with Myocarditis or MIS-C Kidney Disease Liver Disease Crohn's Disease Psoriasis Complement Component Deficiency Asplenia Takes a medication that lowers resistance to infection Takes aspirin or Blood thinners History of Chickenpox History of Gillian-Barre syndrome Diabetes/Metabolic Disorder History or family history of Nervous System Disorder Asthma/RAD Received blood products or immune gamma globulin in the last year CSF Leak Cochlear Implant Weakened Immune System, Cancer, Lupus, HIV/AIDS None of the above A Super Shot staff member will review the patient's vaccine records via CHIRP, Indiana's Vaccination Registry, to identify which vaccines are needed. Once all information is collected and prepared, the staff member will reach out to the number you listed on this registration form to schedule a home visit with you. If you do not hear from us within 5 business days, please call the office at (260) 424-7468. Communication It's ok to call me It's ok to TXT me The HIPAA Notice of Privacy Policy available at https://supershot.org/privacy-policy/ CDC Vaccine Information Statements for any vaccines the child named above may receive are available at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html I have read and understand all information provided at the links above and understand the benefits of vaccines, as well as the risks which includes the contraindications, precautions, and possible side effects of each vaccine administered. I give Super Shot permission to communicate information provided with other healthcare providers as needed, for EMR data entry, insurance billing for services provided, and storage according to Indiana Department of Health policies. I relieve Super Shot, Inc and all personnel of any liability for any reactions that may occur. I have the legal authority, based on my relationship to the child named above, to consent to vaccine administration.Parent/Guardian Signature(Required)Parent/Guardian Name(Required)Date(Required) MM slash DD slash YYYY
