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  • COVID-19: Vaccinations: FAQs

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  • COVID-19 Vaccinations: General FAQs

    • The ATAGI advice does not recognise a mental health condition as a medical contraindication to COVID-19 vaccination.

      However, ATAGI has advised that if the potential recipient of a vaccine is a risk to themselves or others during the vaccination process, a temporary vaccination exemption may be appropriate. This is a matter for your clinical judgement.

      In forming your clinical opinion, you should:

      • Have an in-depth discussion with the patient about their concerns about vaccination, and what their attitudes to vaccination are.
      • Take a full past medical and psychiatric history. This may include seeking information from previous treating practitioners (with patient consent).
      • Undertake a full psychiatric examination of the patient.
      • Assess the risk of self-harm.
      • Consider how well you know the patient.
      • Decide if the patient requires emergency hospital management due to being a risk to themselves or others.
      • Ensure the patient is receiving appropriate management of any mental health condition. 
      • Decide if the patient would benefit from a specialist psychiatric consultation.
      • Consider if it is apparent they have decided to not receive a vaccination, and they are falsely attempting to use mental health grounds.

      A number of patients are concerned about having the COVID-19 vaccination or about the steps that their employer is taking to mandate the vaccination. You will need to form a clinical opinion about whether concern about COVID-19 vaccination amounts to the patient being “a risk to themselves or others during the vaccination process”. In forming this opinion consider:

      • whether the patient states that the only risk would be if they were to undergo the vaccination process
      • the patient’s mental health history – do they have a confirmed history of any mental health condition, or have a chronic mental health condition and has this ever posed a risk to themselves
      • has the patient ever sought mental health assessment or management in the past
      • does the patient have any apparent psychiatric condition other than their stated risk specific to vaccination
      • is the patient resistant to you seeking information from their usual or past treating practitioners
      • is the patient unwilling to engage with your assessment and management of their condition, and
      • is the patient unwilling to undergo formal specialist psychiatric assessment and management to improve their stated mental health concerns.

      If you form a clinical opinion that it is appropriate to provide an exemption on the basis of a mental health condition, you should further note:

      • ATAGI advises exemptions are for acute major medical conditions, rather than chronic conditions. Acute conditions are typically time-limited.
      • ATAGI advises that the exemptions should be temporary and are not recommended for more than six months in the first instance.
      • The Australian Immunisation Register (AIR) exemption form allows for temporary exemptions for an “acute major medical illness”, and it must be due to a “non-permanent contraindication”. There is no exemption permitted for permanent or chronic mental health conditions.

      For further information:

      ATAGI expanded guidance ATAGI Expanded Guidance on temporary medical exemptions for COVID-19 vaccines | Australian Government Department of Health

      AIR exemption form Australian Immunisation Register (AIR) - immunisation medical exemption form (IM011) | Services Australia

    • ATAGI has advised that influenza vaccines can be administered at the same time as the COVID-19 vaccine.

      For more information see ATAGI advice on seasonal influenza vaccines in 2022 | Australian Government Department of Health

      ATAGI advises that COVID-19 vaccines can also be co-administered with other vaccines. However, ATAGI has cautioned that there is currently limited evidence in relation to this, and that there is a potential for increased mild to moderate adverse events when two or more vaccines are co-administered. ATAGI therefore advises that vaccine providers should weigh up the opportunistic need for co-administration compared to giving the vaccines at different times.

    • Some key points:

      In order to assess whether it is clinically appropriate to provide a medical certificate granting a COVID-19 vaccination exemption, we suggest you take the following steps.

      Step 1: Take a patient history

      You should first take the patient’s history, including the patient’s reasons for the request and the context in which they wish to use the certificate.

      Step 2: Determine whether it is clinically appropriate to provide a certificate

      In determining if it is clinically appropriate to provide a certificate, you should have regard to:

      In addition, you should take into account:

      • the nature of the request – a belief that vaccines are not necessary or harmful is not a reason to provide an exemption certificate.
      • whether the patient is asking you to be untruthful.
      • whether a specific form is required for the exemption.

      Please note that it may be helpful for you to use a specific exemption form even if the form is not strictly required. It gives you and the patient clear guidance about clinical contraindications for vaccination and may be helpful in your discussions with the patient.

      In practice, there are very limited circumstances where a patient would have a contraindication to every type of vaccine that may be available.

      Step 3: Discuss the issues surrounding COVID-19 vaccines with your patient

      • If your patient wishes to discuss information they have obtained from sources you believe are not credible, you may wish to discuss that information with them.
      • If it is clear their views are fixed, you can advise them that you will only be guided by information provided by credible sources, including the departments of health, ATAGI, TGA and specialist colleges.
      • You may choose to advise them that you cannot meet their request and terminate the consultation.

      Would you like further information?

       

    • Unfortunately, the answer to this question is complex.

      Ahpra and the National Boards have provided guidance, which you can find at Facilitating access to care in a COVID-19 environment: Guidance for health practitioners

      To help you navigate this issue and minimise the chances of running into a legal problem, we suggest you consider the following issues before you refuse to treat an unvaccinated patient.

      Step 1: Check public health directions in your state and territory

      Most state and territory public health directions do not currently prevent a patient from entering a medical practice if the patient is not vaccinated against COVID.

      Step 2: Obligation to treat a patient

      As general rule, a doctor does not have to treat a patient (even in an emergency) if there is a risk to the doctor’s health and safety or the health and safety of other patients under the doctor’s care (see clause 3.5 of Good medical practice: a code of conduct for doctors in Australia).

      In NSW, the situation is slightly different because, under the Health Practitioner Regulation National Law (NSW), it is unsatisfactory professional conduct to refuse or fail to attend a person in need of urgent attention when requested to do so. The exception is when the practitioner has taken all reasonable steps to ensure that another medical practitioner attends instead within a reasonable time.

      Step 3: Consider whether not treating a patient could be discrimination

      You can refuse to treat an unvaccinated patient except when the patient is unvaccinated for a reason such as:

      • the patient’s medical condition(s)
      • the patient’s age (for example, because the TGA has not approved vaccination for their age group)
      • the patient’s religious beliefs.

      Even then, it can be lawful to discriminate to protect the health and safety of people in the practice.

      In order to minimise the risk of a complaint, you should consider whether there is another way that the medical service can be provided to the patient (for example, via telehealth or in a part of the practice that other patients and staff cannot access).

      Step 4: Consider work health and safety issues

      Under the Medical Board’s code of conduct (see clause 3.4.5 of Good medical practice: a code of conduct for doctors in Australia), as a doctor, you have an obligation to keep yourself and your staff safe when caring for patients: “If a patient poses a risk to your health and safety, or that of your staff, take action to protect against that risk. Such a patient should not be denied care if reasonable steps can be taken to keep you and your staff safe.”

      You also have obligations as a worker under work health and safety laws to ensure the health and safety of those at the practice.

      The law says that you must undertake a risk assessment in consultation with the practice and practice staff to work out the risks associated with managing unvaccinated patients and what measures should be put in place to minimise or eliminate those risks.

      Avant’s factsheet: Managing COVID-19 health and safety risks in medical practice explains the risk assessment process.

      Step 5: Other factors

      A patient might still make a complaint even if you are not discriminating against the patient and you have determined that you can only treat vaccinated patients for health and safety reasons.

      Some things you can consider to minimise this risk include:

      • treating a patient who is partially vaccinated or who has an appointment to be vaccinated in the near future
      • treating unvaccinated existing patients with a known history of compliance with safety rules but not new patients
      • terminating the doctor patient relationship with patients who become aggressive in response to requirements about vaccination
      • the capacity of the patient to obtain treatment elsewhere (for example, denying treatment at a small country GP practice, as opposed to a city practice)
      • the patient’s need for continuity of care (having regard to factors such as the urgency of care, the value of an ongoing treating relationship etc).
       

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    COVID-19 Vaccinations: Consent

    • You should always obtain consent when providing a vaccine.

      However, it may be appropriate for a brief consent discussion to occur when patients have already had at least one dose, taking into account:

      • If the patient had the same brand of vaccine for their previous dose.
      • If there is any new significant information about a brand of vaccine that was previously administered that should now be provided to the patient.
      • If the patient had an adverse event following immunisation.
      • If the patient has any questions or expresses reservations.
      • If the patient has not previously received a dose from your practice.
      • If there has been any change in the patient’s medical history.

    • Children who have previously had COVID infection can receive a vaccine after at least three months after their infection. ATAGI has confirmed this includes children with a past history of PIMS-TS or post COVID condition (‘long COVID’).

    • ATAGI currently recommends the two doses of the Pfizer and Moderna vaccine be given to children eight weeks apart.

      That interval can be shortened to a minimum of three weeks (Pfizer) or a minimum of four weeks (Moderna) in the following special circumstances:

      • prior to the initiation of immunosuppression
      • prior to international travel
      • in an outbreak response.
       

    • ATAGI has recommended that the first dose is the child dose, and the second dose should be an adolescent/adult dose given eight weeks later.

    • As with any course of treatment, if your patient does not complete the course, you should explain the potential outcomes.

      You cannot force your patient to have the second dose if they do not wish to have it. We recommend you document your advice and the patient’s decision in their medical record.

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    Avant Resources on consent and capacity

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    COVID-19 vaccinations: Medicare

      • For practices participating in the COVID vaccination rollout, there are four types of Medicare item numbers specifically associated with the provision of COVID vaccinations:
      • 1 Vaccine Suitability Assessment Services
      • 2 In-Depth Patient Assessments
      • 3 Flag-Fall Arrangements
      • 4 Vaccine Booster Incentive.

      These Medicare items are only available for participating practices.

      Vaccinations must be bulk-billed for everyone living in Australia who is Medicare-eligible, including all Australian citizens, permanent residents, and most visa-holders.

      Vaccine Suitability Assessment (VSA) Services

      The Department of Health has released information about these 16 item numbers.

      The services have to be billed in the name of the supervising GP, who must be present at the location at which the service is undertaken (including for the observation time).

      The services can be undertaken face-to-face by a suitably qualified health professional. However, the supervising GP must accept full responsibility for the service.

      The assessment cannot be done by telehealth.

      A supply of the vaccine must be available for immediate administration. However, the item number should be billed if a patient declines the vaccine after the assessment has been performed.

      If a patient undergoes a VSA and declines the vaccine at that visit but then returns to have the vaccine on another day, a second VSA can be billed when they return.

        You need to ensure you comply with record-keeping requirements to demonstrate a VSA has been conducted appropriately, including:
      • patient name
      • separate dated entry for each attendance for a VSA
      • recording of consent
      • clinical information adequate to explain the service
      • be sufficiently comprehensible so another doctor can rely on the record to effectively undertake ongoing care as it relates to COVID vaccinations.
      VSA items are exempt from the 80/20 rule.

      In-Depth Patient Assessments

        The Department of Health has released information about these two item numbers:
      • must be billed in conjunction with a Vaccine Suitability Assessment Service.
      • can only be claimed where an in-depth clinical assessment regarding a patient’s individual health risks and benefits associated with receiving a COVID vaccine is undertaken.
      • must take at least 10 minutes.
      • can only be claimed once per patient, at either the first or second dose. It cannot be claimed if it has already been claimed by another doctor.

      The doctor must attend the patient in person, you cannot delegate this task to anyone else. Please note that you cannot undertake the assessment by telehealth.

      Flag-Fall Arrangements

        The Department of Health has released information about this item number, which:
      • can ONLY be billed when a doctor is performing a COVID vaccine suitability service in:
        • a residential aged care facility
        • a residential disability facility setting
        • a patient’s place of residence
      • must ONLY be billed in conjunction with the first patient seen on each occasion the doctor attends the facility
      • is NOT available for other site visits external to a doctor’s practice.

      Vaccine Booster Incentive

      The Department of Health has released information about this item number.

      It is to be claimed in conjunction with the appropriate Vaccine Suitability Assessment Service item when a patient receives a third or booster dose. It cannot be claimed for second doses.

      Bulk-billing incentives

      Bulk-billing incentives (double for dose one, single for dose two) will be incorporated into the value of the items and will not need to be claimed separately ($10 per dose).

      The double payment of the bulk-billing incentive for the first dose is in recognition that some patients will need longer explanations about the vaccine than others.

      Where both doses have been provided to the patient by the practice, the practice will be eligible for a PIP incentive of $10 (per patient) on completion of the second dose.

    • No, it is not permissible under Medicare rules to charge a fee or co-payment for a service that is bulk-billed.

      The Department of Health has advised general attendance items cannot be used to triage or screen patients before booking or performing a Vaccine Suitability Assessment.

      This means that, for patients who are making bookings to have the vaccine, you cannot routinely book and charge them for a general attendance item first.

      You cannot charge any “new patient fee” or similar.

      Doctors and practices have been required to refund fees to patients and have been removed from participating in the vaccination rollout, when they have not complied with this.

    • You can only do this if your patient requires a service unrelated to the vaccine. You cannot claim any item other than a VSA, In-depth Assessment, Flag-fall or Vaccine Incentive Booster for the administration of the vaccine.

      The Department of Health prefers that patients presenting with multiple clinical matters be encouraged to book a separate consultation, and preferably with their usual practice. However, there may be some circumstances where deferring treatment is not feasible or in the patient’s best interests. In these situations, standard MBS multiple same-day attendance rules apply.

      Your medical record will be important to demonstrate that this is a separate service. We recommend you make detailed notes about each service. The Department of Health recommends that you state: “The additional service [MBS item…] is clinically relevant but not related to the vaccine suitability assessment service [MBS item…].”

      The practice must obtain and document the patient’s informed financial consent to ensure that the patient understands there is no cost associated with the COVID-19 vaccine. You must inform patients if any other service that they receive on the same occasion will be bulk-billed or subject to a patient co-payment.

        The vaccine suitability assessment service items cannot be co-claimed with:
      • MBS bulk-billing incentive items 10990, 10991 and 10992.
      • MBS item 10988, for an immunisation service provided by an Aboriginal and Torres Strait Islander health practitioner on behalf of, and under the supervision of, a GP.
      • The Department of Health has provided scenarios to help you understand where co-claiming might be suitable.

    • No.

      The Department of Health has stated that the COVID-19 vaccination MBS items have been exempted from the 80/20 rule.

      Any general attendance items billed where COVID-19 vaccinations are discussed will still be included in the 80/20 rule.

    • You can claim other Medicare items numbers when a patient suffers a significant adverse reaction to a vaccine to allow you to provide appropriate treatment.

        Significant adverse reactions include:
      • syncopal episode
      • severe allergic reaction such as anaphylaxis
      • strong, adverse mental or emotional reaction.

        The Department of Health further advises:
      • the treatment is the responsibility of the same doctor who undertook or supervised the Vaccine Suitability Assessment
      • the treatment must be bulk-billed
      • the adverse reaction must be reported to the TGA or state/territory health department.

    • Yes, however, you cannot charge for this, either to Medicare or by private billing.

      You are not expected to provide this service as part of any agreement with the Department of Health.

      You may choose to refer patients who are not Medicare-eligible to a state-based vaccine delivery site, to a Commonwealth Vaccination Clinic (previously known as a General Practitioner-led Respiratory Clinic) or to another other clinic as advised by the Department of Health if these facilities are not available. They will not be charged at these clinics.

    • Doctors at non-participating practices can bill general attendance items for discussions relating to the vaccines. These do not need to be bulk-billed.

      Non-participating practices are not able to bill Vaccine Suitability Assessments, In-depth Patient Assessments or Flag-Falls.

    • The Department of Health has advised that action will be taken for any use of Medicare items that is not in accordance with guidelines and legislation.

      In addition to usual Medicare compliance, doctors and practices are being contacted by the National COVID Vaccine Taskforce when complaints have been made about their billing. In some cases, doctors and practices are being required to undertake extensive audits, and to repay considerable amounts to patients or Medicare.

      The Taskforce states it may revoke a practice’s participation in the vaccine rollout if necessary.

      We recommend that you contact Avant for advice if you are contacted by the National COVID Vaccine Taskforce or Medicare.

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    COVID-19 vaccinations: Practice management

    • Many practices have asked us whether an unvaccinated healthcare worker with a vaccine exemption can attend work. We suggest the following process when considering this request.

      Step 1: Consider the current public health direction

      The first step is to check whether a public health direction requires private sector healthcare workers to be vaccinated against COVID. Healthcare workers in NSW, ACT and NT are no longer required to be vaccinated against COVID by a public health direction.

      If a public health direction does not apply, the practice can allow unvaccinated workers to return to work at the practice and can employ unvaccinated workers (subject to our comments below).

      If a public health direction applies, the practice and its workers must comply with the direction.

      In most jurisdictions, the public health direction allows an unvaccinated healthcare worker to attend work if they are unable to be vaccinated due to a medical contraindication.

      There are two parts to this test:

      1. 1. The healthcare worker has a medical contraindication (which will generally be certified in a vaccine exemption form or on the Australian Immunisation Register)
      2. 2. The healthcare worker is unable to be vaccinated due to the medical contraindication (see step 2).


      In some jurisdictions, the public health direction also has specific requirements about a healthcare worker attending work (such as a requirement for the practice to undertake a risk assessment or regular COVID tests, or to wear particular PPE).

      Step 2: Seek information about the healthcare worker’s medical contraindication

      The practice may need information about the nature of the healthcare worker’s medical contraindication in order to consider whether and for how long the healthcare worker is unable to be vaccinated, and to undertake a risk assessment.

      It will generally be reasonable to require a healthcare worker to provide information about their medical contraindication for these purposes.

      In some cases, the reason relied upon in an exemption certificate may not amount to a medical contraindication which prevents the person from being vaccinated. For example, ATAGI has confirmed there is not a medical contraindication to vaccination where a person has had a COVID infection and recovered from the acute illness (see our related FAQ here).

      The practice should ensure that it does not inadvertently discriminate against a healthcare worker based on the healthcare workers’ disability. Any control measures or decision about attendance at work should be based on objective criteria and should be confirmed in writing.

      Step 3: Practice risk assessment

      Work health and safety legislation requires the practice to ensure the health and safety of the healthcare worker and other persons at the practice as far as reasonably practicable. This obligation continues even if a public health direction permits an unvaccinated healthcare worker to attend the workplace.

      The practice should conduct a risk assessment to consider the risks of an unvaccinated healthcare worker attending the practice. You can find further information in our factsheet at Avant - Managing COVID-19 health and safety risks in medical practice.

      That risk assessment may conclude:

      1. 1. It is safe for the healthcare worker to attend work.
      2. 2. It is not safe for the healthcare worker to attend work.
      3. 3. It is safe for the healthcare worker to attend work provided certain additional control measures are put in place.

    • Unfortunately, the answer to this question is complex.

      Ahpra and the National Boards have provided guidance which you can find at Facilitating access to care in a COVID-19 environment: Guidance for health practitioners.

      To help you navigate this issue and minimise the chances of running into a legal problem, we suggest you consider the following issues before you refuse entry to an unvaccinated patient.

      Step 1: Check the public health directions in your state and territory

      State and territory public health directions do not currently prevent a patient from entering a medical practice if the patient is not vaccinated against COVID.

      Step 2: Obligation to treat a patient

      As general rule, a doctor does not have to treat a patient (even in an emergency) if there is a risk to the doctor’s health and safety or the health and safety of other patients under the doctor’s care (see clause 3.5 of Good medical practice: a code of conduct for doctors in Australia).

      In NSW, the situation is slightly different because under the Health Practitioner Regulation National Law (NSW) it is unsatisfactory professional conduct to refuse or fail to attend a person in need of urgent attention when requested to do so. The exception is when the practitioner has taken all reasonable steps to ensure that another medical practitioner attends instead within a reasonable time.

      Step 3: Consider whether the decision not to treat the patient may be discriminatory

      You can refuse to allow an unvaccinated patient to enter your practice except when the patient is not vaccinated for a reason such as:

      • the patient’s medical condition
      • the patient’s age (for example, because the TGA has not approved vaccination for their age group)
      • the patient’s religious beliefs.

      It can be lawful to discriminate if it is necessary to ensure the health and safety of people in the practice.

      However, the practice should first consider whether there is another way to provide a service to the patient other than through entry to the practice (for example, via telehealth or with staff dressed in full PPE).

      Step 4: Consider work health and safety issues

      Under work health and safety laws, practices must ensure the health and safety of their workers, patients and others at the workplace.

      Your practice should undertake a risk assessment in consultation with practice staff to determine whether patient vaccination against COVID is necessary to ensure health and safety in the workplace. Avant’s fact sheet: Managing COVID-19 health and safety risks in medical practice explains the risk assessment process.

      Your practice should already have policies in place for dealing with:

      • how you initially see patients
      • the use of personal protective equipment (PPE)
      • how you manage cases where patients have COVID symptoms.

      Step 5: Other factors

      Your practice may wish to consider other factors before making a decision to refuse treatment to an unvaccinated patient:

      • the reason the patient is not vaccinated (e.g. the patient intends to be vaccinated but has had difficulties accessing vaccination)
      • whether the patient is a new patient or existing patient
      • if a doctor elects to terminate the doctor-patient relationship or deny treatment to a patient because the patient is not vaccinated, the patient may make a complaint
      • the capacity of the patient to obtain treatment elsewhere (for example, denying treatment at a GP practice versus a specialist practice where there are a limited number of specialists in that area)
      • the patient’s need for continuity of care (having regard to factors such as the urgency of care, the value of an ongoing treating relationship etc)
      • a doctor’s right to conscientiously object to treating patients who are not vaccinated.
       

    • The patient is responsible for making an appointment for any subsequent doses of the vaccine.

      If a patient does not book subsequent appointments at the same time, we suggest that you remind them at their visit to make the appointments for subsequent doses and offer to make that appointment at the clinic.

      If the patient does not attend the practice for subsequent vaccinations, the practice could send an SMS reminder assuming consent has been provided to communicate via SMS.

      Otherwise, we suggest you follow your usual follow-up protocol to recall patients for their subsequent doses.

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    COVID-19 vaccinations: Employment

    • The first step is to check whether a public health direction requires private sector healthcare workers to be vaccinated against COVID.

      If a public health direction applies, the practice and its workers must comply with the direction.

      If a public health direction does not apply, the practice can allow unvaccinated workers to return to work at the practice and can employ unvaccinated workers (subject to what we say below).

      It remains critical for practices to consider the work health and safety risks associated with allowing unvaccinated healthcare workers to work at the practice. Avant’s fact sheet: Managing COVID-19 health and safety risks in medical practice explains the risk assessment process.

        If the practice’s risk assessment determines that workers should be vaccinated against COVID:
      • the practice may be able to issue a lawful and reasonable direction to its employees. Further information about when a direction is lawful and reasonable can be found on the Fair Work Ombudsman website; and
      • the practice may be able to make it a contractual requirement for workers other than employees to be vaccinated against COVID.

      The practice should carefully consider any COVID vaccine exemption and/or specific information about a worker’s inability to be vaccinated against COVID when determining what steps to take in relation to recruitment and employment decisions. This will minimise the risk of a successful discrimination claim on a ground such as religion, disability or pregnancy.

    • The first step is to check whether a public health direction requires healthcare workers to be vaccinated against COVID. If a public health direction applies, a public sector healthcare worker must be vaccinated in accordance with the direction.

      The next step is to consider whether there is a Health Department directive requiring healthcare workers to be vaccinated against COVID. These directives are generally made under legislation and are legally enforceable.

      The final step is to consider whether there is a local hospital/health service direction for healthcare workers to be vaccinated against COVID. These directions are purportedly enforced as “lawful and reasonable” directions. Further information about when a direction is lawful and reasonable can be found on the Fair Work Ombudsman website.

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