Request a Flu Shot Clinic

Size of Location	Length of Clinic
51 - 149 employees	3 hours
150 - 399 employees	4 hours
400 - 749 employees	5 hours
750 - 1,000 employees	6 hours
Over 1,000 employees	Please contact LabCorp to discuss

Agency/Academic Institution Name

Street address 1

Street address 2

City

State

ZIP code

County

Agency/Academic Institution Contact Name

Contact Phone Number - -

Contact Email Address

Secondary Contact Name

Secondary Contact Phone Number - -

Secondary Contact Email Address

Date for Flu Clinic (A minimum of six weeks notice is required, subject to availability.) Clinics for the 2020 flu season will begin September 14, 2020.

1^st Choice*:

2^nd Choice*:

3^rd Choice:

Flu Clinic Times Start: End:

Are there multiple shifts? Yes No

Shift Flu Clinic Times Start Start: End:

Location of clinic (building/room)

Total # of anticipated flu shots at this clinic location. The quadrivalent vaccine will be offered and self-funded groups will be charged $33 per shot. There is a 25-shot minimum per scheduled clinic time, includes split shifts. If your Agency does not meet the 25-shot minimum, your Agency will be responsible paying $25 per shot for any shots short of this minimum. Your Agency will be invoiced for this amount. If the invoice is not paid by the stated payment term of 30 days, the invoice amount will be added to the Agency's next monthly premium invoice. As all premium invoices must be paid as billed, the Agency shall pay the full premium invoice, including this added amount, or the Agency's claims will be held.

Total # of anticipated flu shots at all clinic locations (If more than one clinic is being scheduled)

If the answer to the 2 questions above is 100 or greater, would you like LabCorp to set up an online schedule for your employees to register themselves for their flu shot appt? Yes No

Have you offered flu shots in the past? Yes No

If so, how many shots were provided?

Will family members be invited to the clinic? Yes No

Will retirees be invited to the clinic? Yes No

Will employer pay for non-SHP covered employees?
(Non-member cost is $35.) Yes No

Would you like to request multiple or split-shift clinics?

Are there security procedures for LabCorp to follow during the day of the clinic? Yes No

Please provide detailed directions to location and parking instructions.

Special Notes and Considerations

If you have questions, please contact your Blue Cross NC Representative or LabCorp Services at fluclinics@labcorp.com.

By clicking I AGREE, I acknowledge:

There is a 25 shot minimum per clinic required (For example, if there are 2 clinic sessions on the same day or multiple sessions on different days, each session must have 25 participants.)
The listed Agency/academic institution will be charged $25.00 per shot for any shots short of the 25-shot minimum per clinic.
If the listed Agency does not pay this charge, it will be added to the Agency's premium invoice.
I understand there are no exceptions to the 25-shot minimum per clinic requirement.

I Agree * I Do Not Agree

The person listed below has signing authority and responsibility for the payment of any bill associated with this flu shot clinic (includes $25.00 per shot for any shots short of the 25-shot minimum per clinic). An email that a flu shot clinic has been requested will be sent to the email address listed below.

Name *

Title*

Email Address*

Date

State Health Plan Request Form

Use this guide to help determine how long your flu shot clinic could be.

A request form is required for each unique clinic location.