ATTENTION SHINGLES VACCINE CLINIC PARTICIPANTS:

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2 Dear staff member: 2017 Vaccine clinic provided by Diversified Solutions Your school s immunization clinic has been scheduled through your school district s contact. Please read the following information: The vaccines being provided this year are: Influenza Virus Vaccine Formula for clients and their dependents age 5 or greater. This is the only vaccine provided to minor dependents. Also available in limited supply: Tdap Tetanus, Diphtheria, Acelluar Pertussis (Whooping Cough)** MMR (Measles, Mumps, and Rubella)** Pneumonia 23 Shingles (age 50 and over if plan covers for age 50) PRIOR REGISTRATION IS REQUIRED. SEE ATTACHED SHINGLES REGISTRATION FORM FOR EACH PERSON DESIRING THE SHINGLES VACCINE. Answers to questions frequently asked: A consent form for each vaccine you want must be completed for anyone receiving a vaccine. A parent/guardian must sign the flu vaccine consent form for their child and provide the child s approximate weight. It is best for the parent/guardian to accompany any young child. **Please remember to bring your insurance card to the clinic.** Reminder: Pregnant women MUST have a written note from their primary care provider authorizing the flu vaccine administration. No other vaccines can be provided to pregnant women through this clinic. Other insurances for which Diversified Solutions will file other than your District s insurance, ASBAIT/Meritain: BCBSAZ, Federal BCBSAZ and other Out of Area BCBS. **Medicare and Medicare alternative insurance plans, such as Humana, Secure Horizons, Sterling, or Railroad Medicare. We CANNOT accept Senior BCBSAZ, however. Medicare will NOT pay for the Tdap, Shingles, or MMR vaccines but will cover the Flu and Pneumonia vaccines. For those not covered by the above insurances or Meritain, we accept cash or check, but have no method for accepting a debit or credit card. For further information please see the flyer attached to this or POSTED ON YOUR CAMPUS. The CDC website has information available prior to the clinics on each vaccine. Please let us know if you have any other questions. Thank you, Diversified Solutions Staff.

3 Shingles Vaccine Information AND Registration Form 2017 IMPORTANT information below PLEASE REVIEW and RESPOND IMMEDIATELY IF YOU WANT THE SHINGLES VACCINE. We have scheduled your on-site vaccine clinic with your district. If you wish to receive a Shingles Vaccine your vaccine will be purchased only after you have preregistered to receive the vaccine. REGISTRATION DEADLINE Minimun 2 weeks before your scheduled clinic. dspayson@diversified--solutions.com (note there are 2 dashes between diversified and solutions) completed form or fax to (928) Once your eligibility is confirmed you will be sent an and placed on a list for the vaccine. You must bring your confirmation to the clinic. Supplies are limited and registration does not guarantee vaccine availability. The physician supervising the administration of this clinic would like you to review the health risks associated with this shot to be sure you are eligible to receive the vaccine. IF YOU HAVE ANY QUESTIONS WHETHER YOU SHOULD OR SHOULD NOT TAKE THE VACCINE CONTACT YOUR PHYSICIAN. Due to the high cost of the vaccine (it costs between $200-$300), we would like you to review the requirements below and contact us at dspayson@diversified--solutions.com if you are unable to take the vaccine once you have been approved. ATTENTION SHINGLES VACCINE CLINIC PARTICIPANTS: As your Shingles Prevention Clinic approaches, we would like to make you aware of a few things regarding the Shingles Shots and issues which mean that you CANNOT receive the vaccine: 1. History of anaphylactic reaction to gelatin, neomycin or other component of the vaccine (this may include trace quantities of bovine calf serum) 2. History of primary or acquired immunodeficiency states including leukemia, lymphomas, or other malignant neoplasms affecting the bone marrow or lymphatic system. "With a Doctor's order, those whose leukemia is in remission and who have not received chemotherapy or radiation for at least 3 months can receive zoster vaccine." 3. On immunosuppressive therapy, including high-dose corticosteroids. If long-term Highdose therapy has concluded, one month or more must have passed prior to receiving Zoster vaccine. (Short-term or low dose corticosteroid therapy of less than 14 days of a low-tomoderate dose (<20 mg/day of prednisone or equivalent) is acceptable for receiving the Shingles vaccine). 4. Active untreated TB 5. Women who are or may become pregnant. Pregnancy should be avoided for 3 months following vaccination.

4 6. Persons taking chronic antiviral medications such as acyclovir, famciclovir or valacyclovir should discontinue medications for at least 24 hours before receiving the zoster vaccine. These medications should not be used for at least 14 days after vaccination. 7. AGAIN, PLEASE CONTACT US IMMEDIATELY AT solutions.com IF YOU HAVE REGISTERED AND THEN FIND YOU ARE UNABLE TO TAKE THE VACCINE

5 Shingles Vaccine Registration Form Please review the previous Shingles Vaccine Information Sheet before registering for the vaccine In order to receive the zero out-of-pocket cost Shingles vaccine for eligible employees, you must have reviewed the Shingles Vaccine Information sheet and complete the following registration form before the registration deadline (2 weeks before your scheduled clinic see your school s flier). You may either fax this form or it to: Fax or dspayson@diversified-- solutions.com All insurance is verified before a vaccine is ordered so ALL information must be completed. If this is for a spouse on your plan be sure to list the name, age and DOB for them. IF YOU PREVIOUSLY RECEIVED A SHINGLES VACCINE YOU DO NOT NEED ANOTHER ONE: THIS IS ONLY FOR THOSE HAVING MERITAIN OR BLUE CROSS BLUE SHIELD INSURANCE OR CASH. NO OTHER INSURANCE INCLUDING MEDICARE IS COVERED. Cash Price is $ This is only to purchase and reserve a Shingles vaccine for you. Name: Age: DOB School District: School where you would like to receive the vaccine: Group ID: Insurance ID: Spouse (if wants to receive): Name: Age: DOB: This vaccine costs over $200 and Diversified Solutions is investing in this vaccine based on your registration. Please do everything you can to get the vaccine when it is offered. Your school will be notified of the date. Please notify us in the event that you cannot receive the vaccine once you have signed-up so we can give it to someone else. Thank you. Registration Form 2017