Patient Eligibility Screening Record

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. Providers using a

similar form (paper-based or electronic) must capture all reporting elements included in this form.

1. Child’s Name :___________________________________________________________________________________

Last Name

First Name

MI

2. Child’s Date of Birth: __ __/__ __/__ __ __ __

3. Parent/Guardian/Individual of Record:__________________________________________________________________

Last Name

First Name

MI

4. Primary Provider’s Name:___________________________________________________________________________

Last Name

First Name

MI

5. To determine if a child (0 through 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. If Column A-D is marked, the child is eligible for

the VFC program. If column E, F or G is marked the child is not eligible for federal VFC vaccine.

Not eligible for VFC Vaccine

Eligible for VFC Vaccine

A

B

C

D

E

F

G

Has health

Medicaid

No Health

American

*Underinsured

insurance

**Other

***Enrolled in

Enrolled

Insurance

Indian or

served by FQHC,

Date

that covers

underinsured

KidsCare

RHC or deputized

Alaskan

provider

vaccines

Native

*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

covered by insurance. 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 provider or facility is not a

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.

***Children enrolled in 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.

Please be advised:

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.

Thank You.

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

Signature: _______________________________________________Date:_______________________