Vaccine for Children Eligibility Screening Form

Vaccines for Children (VFC) Program Patient Eligibility Screening Record

A record of all children 18 years of age or younger who receive immunizations must be kept in the health care provider's office for 6 years. The record may be completed by the parent, guardian, individual of record, or by the health care provider. VFC eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure the child's eligibility status has not changed. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine. similar form (paper-based or electronic) must capture all reporting elements included in this form.

1. Child's Name*

First NameMiddle InitialLast Name

2. Child's Date of Birth*

Date

3. Parent/Guardian/Individual of Record: *

First NameLast Name

4. Primary Provider's Name

Child's Primary Doctor

5. To determine if a child (0-18 years of age) is eligible to receive federal vaccine through the VFC and state programs, at each immunization encounter/visit enter the date and mark the appropriate eligibility category. *

Rows	Enrolled in Medicaid	No Health Insurance	American Indian or Alaskan Native	Underinsured (has insurance that doesn't cover vaccines)	Has health insurance that covers vaccines
Select one

*Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that are not coveredbyinsurance. In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputized provider. The deputized provider must have a written agreement with an FQHC/RHC and the state/local/territorial immunization program in order to vaccinate underinsured children.

** Other underinsured are children that are underinsured but are not eligible to receive federal vaccine through the VFC program because the providerorisnota facility

FQHC/RHC or a deputized provider. However, these children may be served if vaccines are provided by the state program to cover these non-VFC eligible children.

**Childrenenrolledin separate state Children's Health Insurance Program (CHIP These children are considered insured and are not eligible for vaccines through the VFC program. Each state provides specific guidance on how CHIP vaccine is purchased and administered through participating providers.

If your insurance company does not cover immunizations and you do not let us know at the time of the visit, it is your responsibility to pay the cost involved. We cannot make the Vaccines for Children Program retroactive and you are only eligible for the Vaccines for Children Program at the time of the visit. If you are unsure if immunizations and well check-ups are covered, please contact your insurance company.

Please sign below indicating that you understand and agree with the above statement.

Signature*

Date*

Date