Patient Eligibility Screening Form Page 2

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Patient Eligibility Screening Form Printable pdf

1

2

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)

[Type text]

VFC Eligibility Screening Form 2015

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