Form Dhec 1146d - Vaccines For Children (Vfc) Program Patient Eligibility printable pdf download

Vaccines For Children (VFC) Program

Patient Eligibility Screening Record Form in

DHEC Health Departments

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-C is marked, the child is

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

Eligible for VFC Vaccine

Not eligible for VFC Vaccine

VFC

SC State

Date of

Medicaid

No Health

American

Underinsured

SC State

Underinsured,

Immunization

Enrolled

Insurance

Indian or

served by FQHC,

Insured,

RHC or deputized

(State stock)

visit

(VFC stock)

Alaska

(State stock)

(317 stock- HPV Only

provider

Native

Until stock is depleted)

(VFC stock)

(VFC stock )

N/A

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.

Underinsured children in need of the HPV vaccine must be served with 317 funded HPV vaccine until stock is depleted. 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 an insured child 0 through 18

years of age served in a DHEC Immunization Clinic. 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 1146D (11/2016)

SOUTH CAROLINA DEPARTMENT OF HEALTH & ENVIRONMENTAL CONTROL