PEBB OEBB Insurance Claim Form and Consent Influenza 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your insurance plan details, selecting from options like Kaiser, Moda, or Providence Health Plan. Fill in your Primary Insurance ID number for accurate processing.
3. Complete the personal information section by providing your last name, first name, street address (where you receive insurance paperwork), city, state, ZIP code, telephone number, date of birth, and gender.
4. Answer the health-related questions regarding previous flu vaccinations and any severe reactions. This includes inquiries about Guillain-Barre Syndrome and current health status.
5. Indicate any allergies to vaccine components and whether you are pregnant. Review the consent statement carefully before signing.
6. Sign the form as a responsible person and indicate your relationship to the insured. Ensure that all fields are completed accurately before submission.

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