Patient Eligibility Screening Form printable pdf download

For Healthier Lives

MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

IMMUNIZATION PROGRAM

VACCINES FOR CHILDREN PROGRAM (VFC)

Immunize

Patient Eligibility Screening Form

For use in all Provider Sites, except Federally Qualified Community Health Centers

Initial screening

Initial screening date ________________________ Child’s date of birth ________________________

Child’s full name ____________________________________________________________________

Parent, guardian or legal representative’s full name _________________________________________

Health care provider’s full name ________________________________________________________

This form must be completed for

Check only one box below:

all children under 19 years old at

their initial visit, updated every

This child is eligible for immunizations through the federal VFC

time a vaccine is given and kept

program because he/she*:

in the child’s medical record or

on file in the office.

is enrolled in Medicaid (includes MassHealth and HMOs, etc., if

enrolled in Medicaid)

The form may be completed by

does not have health insurance

the parent, guardian, or legal

is American Indian (Native American) or Alaska Native

representative, or by the health

care provider.

This child is not VFC-eligible because he/she:

Verification of responses is not

has health insurance (that covers all recommended childhood and

required.

adolescent vaccinations) and is not American Indian (Native

American) or Alaska Native

*This form identifies which children are eligible for vaccines through the federal Vaccines for Children

(VFC) program. If one of the first three boxes in the section above is checked, the child is VFC eligible.

Screening at each subsequent visit (documentation required)

VFC Eligible

Not VFC Eligible

Is enrolled in Medicaid

Is American Indian

Does not have

Has health

(includes MassHealth and

Date

(Native American)

health insurance

insurance

HMOs, etc., if enrolled through

or Alaska Native

Medicaid)

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VFC Eligibility Screening Form 2015

Patient Eligibility Screening Form

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