Adult Immunization Program

Vaccine Administration Record

Name Date of Birth

Street Address, City, State, Zip

Telephone Race Sex Social Security Number PATS ID Number (Staff Use Only)

M F
Preferred Method of Contact: Call Yes No Mail Yes No
Preferred Phone/Address (if different from above)
Alternate Method of Contact:
Emergency Contact: Emergency Phone:

Medicare Card Number

(include alpha suffix)
Medicaid Card Number

Other Insurance: Company Policy Number

Name and SS# of Policy Holder

The client Bill of Rights has been reviewed with the client or client's legal guardian? Yes

Billing Certification & Privacy Notice

By my signature below as parent, guardian or client, I request that payment of Medicare/Medicaid or other Third Party
Insurance benefits be made on behalf of the South Carolina Department of Health and Environmental Control for any
services provided me. Permission is also granted to DHEC to exchange medical or other confidential information as
necessary to the Center For Medicare and Medicaid Services (CMS), its agents or other agents needed to determine
these benefits for related services.

If applicable, I also agree to participate in treatment plans, assignment of insurance, Medicaid or Medicare benefits to
DHEC for services rendered and to participate in payment for services as determined by specific program guidelines.

I acknowledge that I have been provided with a copy of DHEC's Privacy Notice. Patient refused notice? Yes

Signature (Client/Legal Guardian) Date Witness (if client signs with “X”) Date

VACCINE NAME INJECTION INJECTION MANUFACTURER LOT/CONTROL # VIS

SITE ROUTE FORM DATE
INFLUENZA (FLU)
PNEUMOCOCCAL
POLYSACCHARIDE
(PPV23)
TETANUS (Td)

Signature and Title of Person Administering Vaccine(s)/Date Clinic Site or Health Department

DHEC 3518 (05/2003) Side A SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
 Comments

DHEC 3518 (05/2003) Side B

 INSTRUCTIONS for COMPLETING DHEC 3518
Adult Immunization Program Vaccine Administration Record
PURPOSE: To provide staff with a one-page form for documenting immunizations administered, client profile and demographic
data, Medicare/Medicaid/Third Party insurance information, and client medical information. This form is used for documenting
immunizations administered under the Adult Immunization Program (> 19 years of age) only, and alleviates the use of DHEC
forms 755 (Client Profile), 1103 (Vaccine Administration and TB Skin Testing Record), 1619 (Continuation/Coordination Sheet),
and 2021 (Privacy Notice Ackowledgement).
SIDE A
Name - Enter client name. Date-Of-Birth - Enter client DOB (client must be > 19 years of age).
Address - Enter street address, city of residence, state of residence, and associated zip code.
Telephone - Enter client telephone number, or number where client can be reached.
Race - Enter client race. Sex - Check client gender - “M” for Male and “F” for Female.
Social Security Number – Enter client social security number.
PATS ID Number - Record client’s assigned PATS identification number.
***************************Labels may be used to document the above information.******************************
Preferred Method of Contact - If the client indicates it is OK to call or mail protected health information to him/her, check yes
and enter the address where information can be mailed and the phone number where the client can be called, if different from
above. If the client does not want to be contacted by phone or by mail, check no.

Alternate Method of Contact - Enter the name and phone number of a person the client indicates DHEC staff can contact in
case of an emergency.

Medicare/Medicaid/Other Insurance - Enter requested information. If client has two or more forms of coverage, document
coverage information for each.

Bill of Rights - Complete as directed. A copy of the bill of rights can be posted in the area for clients to review. A copy
must be given to the client if he/she request one.

Billing Certification & Privacy Notice - The client or legal guardian should read, sign, and date the form, allowing DHEC
to bill. By signing, the client/legal guardian also acknowledges receiving a copy of DHEC's Privacy Notice. If the client
refuses the privacy notice, check yes. If client is unable to sign his/her name, client should enter an “X” in the signature
field. A witness must sign and date this entry. DHEC staff may witness the “X” signature.

Vaccine Administration Record - For each vaccine administered according to the Adult Immunization Program policy,
document the following information:
• Vaccine Name
• Vaccine Injection Site: Left Arm - LA or “1” Right Arm - RA or “2”
Left Leg - LL or “3” Right Leg - RL or “4”
• Vaccine Injection Route: SQ= Subcutaneous IM = Intramuscular
• Vaccine Manufacturer
• Vaccine Lot/Control Number
• Vaccine Information Statement (VIS) Form Date
The vaccine names, Influenza, Pneumococcal Polysaccharide, and Tetanus have been added for convenience since this
form is used frequently during flu season.

Signature – The person administering vaccine(s) should sign his/her name, title and date.

Clinic Site/Health Department – Enter the name/site code of health department providing the immunization.
SIDE B
Comments – Document any client information deemed necessary, such as allergies to vaccine components or medical
conditions that contraindicate the administration of certain vaccines.

OFFICE MECHANICS and FILING

Enter administered vaccines into the PATS Immunization Module. If the client does not have a PATS number, assign one.
Do not alter the default site code field of PATS. If the client has a medical record, file this form under the “client profile/
history” tab, in chronological order, most recent on top. If the client does not have a medical record, batch file this form
according to the current record format in the Health Record Manual. The current adult health record retention schedule
according to the Comprehensive Health Records Manual applies.
DHEC 3518 (05/2003)