8823 b Form 2023-2024

8823 b Form: What You Should Know

Patients must provide the following items when submitting and submitting their hepatitis B enrollment to pharmacies: 1. Written consent forms, indicating the name, mailing address, and date of birth of the patient and the name, mailing address, and date of birth of the person who will sign and date the consent. 2. Proof of vaccination, from a licensed healthcare provider, indicating if and when the patient has received a licensed vaccine of the same species. 3. Documentation that the person receiving a vaccinated hepatitis B dose is not pregnant, has no chronic health conditions, has received no other licensed or over-the-counter drug for any condition within the past 12 months, and is not abusing drugs. 4. One of the following forms of identification: An original or certified copy (or a certified copy of a passport-type image) of a government-issued photo identification, including: A United States passport or other government-authorized identification card issued by the United States government, a government of Canada, or a government of any other country; or An original or certified copy of a Canadian Driver's License.​​ A United States passport or other government-authorized identification card issued by the United States government or a United States military ID card; or An original or certified copy (or a certified copy of a passport-type image) of a diplomatic visa issued by a foreign country or a United Nations ID card.​ A United States passport or other government-authorized identification card issued by the United States government or a United States military ID card; or An original or certified copy (or a certified copy of a passport-type image) that has been issued by a federally recognized tribal government, state recognized tribal government, or territory of the United States, and is issued with a photo.​ A United States passport or other government-authorized identification card obtained by a foreign national in order to receive a United States visa or residence permit, if the United States government or foreign governmental agency has provided the foreign national with an original or certified copy of a United States passport or other government-authorized identification card that has been issued to that foreign national. If the foreign national's government has provided the foreign national with a United Nations ID card, a passport valid for travel in most foreign countries. Hepatitis ​B​ is a viral disease in humans that can cause chronic liver problems such as cirrhosis (scarring), hepatitis (liver disease), or both.

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