For all travel consultations and vaccines we require payment in full on the day of the visit.
The following form is intended for use when calling your insurance company to establish if you have coverage for vaccines.
Use the member service number on the back of your card. You must be specific that the vaccines are intended for travel purposes
For each vaccine give the name and the CPT code (the number beginning with 90 directly following the name.
Place a check in the space corresponding to that particular vaccine. The insurance company should be able to give you a direct yes/no answer. Ask for written confirmation to be sent to you. Print the form for your records We will gladly supply the appropriate documentation to send to your insurance company for reimbursement.
Check
Vaccine
(CPT Code/ICD-9 Code)
Hepatitis A Vaccine, Inactivated
90632/VO5.3
Hepaittus B Vaccine, (Recombinant)
90747/VO5.3
Hepaittus A and Hepaittus B Vaccine
90538/VO5.3
Influenza Virus Vaccine
90658/Vo4.31
Japanese Encephalitis Virus Vaccine, Inactivated
90735/VO5.1
Measels, Mumps, and Rubetis Virus Vaccine Live
90707/VO5.4
Meningococcal Polysaccharide Vaccine Groups - A, C, Y and W-135 Combined
90734/VO3.89
Pneumococcal Vaccine Polyvalent
90733/VO3.89
Poliovirus Vaccine Inactivated
90732/VO3.82
Rabies Vaccine
90713/VO4.0
Tetanus and Diphtheria Toxolds Adsorbed for Adult Use
90675/VO4.5
Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussls Vaccine Absorbed