Form SSA-268. Patient Acknowledgement Form for Influenza Vaccination

Form SSA-268, the Patient Acknowledgment Form for Influenza Vaccination, is used to acknowledge receipt of the influenza vaccine by patients in healthcare facilities. The primary purpose of this form is to document that patients have received the flu vaccine, including the date and location of vaccination, as required by the Centers for Medicare & Medicaid Services (CMS).

For example, in healthcare settings, patients may be required to receive the influenza vaccine, and this form is used to acknowledge their compliance. The purpose is to ensure that healthcare facilities maintain accurate records of influenza vaccinations for reporting and compliance purposes.

The parties involved are patients and healthcare facilities, such as hospitals, nursing homes, and clinics. The form consists of sections for the patient's information, vaccination details, and a patient acknowledgment signature. Proper documentation is crucial for compliance and record-keeping.