HealthPartners.com - Flu Shot Registration Form

Flu Shot Registration Form

Flu Shots

Company Information Company Name:

HealthPartners Group Number:

Are you
	Fully Insured Self-Insured
Main Phone Number:

Fax Number:

Street Address:


(City, State, Zip Code)

Company Contact Information Contact's Name:

Direct Phone Number:

Email Address:

Program Information Program and Payment Options:
	Include only HealthPartners covered employees Include HealthPartners covered employees and covered dependants Include employees that are not covered by HealthPartner health insurance
Do you have a preferred HealthPartners flu vendor:
	Yes No
If yes, indicate your preferred HealthPartners flu vendor:

If other, specify:

Location Specific Information Number of location(s):

Location #1: Street Address:


(City, State, Zip Code)

HealthPartners Group#:

Estimated number of shots:

Location #2: Street Address:


(City, State, Zip Code)

HealthPartners Group #

Estimated number of shots:

Location #3: Street Address:


(City, State, Zip Code)

HealthPartners Group #:

Estimated number of shots:

For self-insured groups only: The fee for the influenza vaccination and administration is $25.00. This includes the negotiated fee for the vendor, plus a $2.00 administration fee. This will be charged through the Employer's claims for every influenza vaccination participant covered under the Employer's group plan administered by HealthPartners Administrators, Inc. (HPAI). Any additional vendor costs that may apply will be disclosed prior to scheduling the date for the flu shots to be administered. By clicking "Yes" below you acknowledge that you have read, understand, and agree to be bound by the terms above.
	Yes

We look forward to working with you. If we can answer any questions, please call (952) 883-7574. You can also fax the printable version

to (952) 853-8732.