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Vaccines for Children (VFC) Program

Patient Eligibility Screening Record Form

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 3 years or longer depending on state law.

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

Last Name

First Name

3. Parent/Guardian/Individual of Record:_______________________________________________________________________________

Last Name

First Name

4. Provider’s Name:________________________________________________________________________________________

Last Name

First Name

5. To determine if a child (0 through 18 years of age) is eligible to receive publicly funded vaccine through the VFC or 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.

Eligible for VFC Vaccine

Not eligible for VFC Vaccine

VFC

Has health

SC State

Date of

Medicaid

No Health

American

Underinsured

insurance

Underinsured,

Insured,

Immunization

Enrolled

Insurance

Indian or

served by FQHC,

that covers

Served by

Insured Hardship,

RHC or deputized

visit

(VFC stock)

Alaska

vaccines

Non-FQHC/RHC

Vaccine Caps

provider

Native

(State stock)

(VFC stock)

(Private stock)

(VFC stock )

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.

SC State Vaccine Program Underinsured: These children are underinsured but are not eligible to receive federal vaccine through the VFC program because the provider or

facility is not an FQHC/RHC or a deputized provider. However, these children may be served with state vaccine program vaccine to cover these non-VFC eligible children.

Only providers enrolled in the SC State Vaccine Program are eligible to serve this population. You must have SC State Vaccine program vaccine stock prior to seeing this

patient population.

SC State Vaccine Program - Insured Hardship and Vaccine Caps: These children are considered insured and are not eligible for vaccines through the VFC program.

However, these children may be served state vaccine program vaccine to cover these non-VFC eligible children. Insured Hardship is defined as “Health Insurance deductible

is greater than $500.00 per child or $1000.00 per family (Eligible for state vaccine only if the deductible has not been met and the family cannot afford to pay for vaccine).”

Vaccine Caps is defined as “Insured but coverage capped at certain amount and cap has been exceeded.” Only providers enrolled in the SC State Vaccine Program are

eligible to serve this population. You must have SC State Vaccine program vaccine stock prior to seeing this patient population.

DHEC 1146 (Rev. 9/2016)

SOUTH CAROLINA DEPARTMENT OF HEALTH & ENVIRONMENTAL CONTROL