Insured Eligibility Form -South Carolina State Vaccine Program printable pdf download

Insured Eligibility Form -South Carolina State Vaccine Program

South Carolina STATE Vaccine Program:

Insured Eligibility Form

Child’s Name: ________________________________________________________________

Date of Birth: _________________________________________________________________

Insurance Company ____________________________Policy Number ___________________

Name and Insurance ID Number of Policy Holder _____________________________________

Insured STATE Vaccine Eligibility Categories

Check appropriate box(es) regarding eligibility for STATE vaccine, as applicable:

Non FQHC/Non RHC Providers:

 Insured but coverage does not include vaccines (Underinsured);

 Insured but coverage only for select vaccines (eligible for STATE vaccine for non-covered

vaccines only) (Underinsured);

 Insured but coverage capped at certain amount and cap has been exceeded (Underinsured)

All Providers:

 Health insurance deductible $2000 or greater (Eligible for STATE vaccine only if the

deductible has not been met and the family cannot afford to pay for vaccine) (Insured

Hardship).

NOTE: Children who are not eligible for VFC or STATE vaccine must be administered

privately purchased vaccine.

I hereby acknowledge that the information given herein is true and correct. I authorize DHEC to

verify any information contained in this document.

________________________________________________

_______________________

Signature of Patient/Parent/Guardian

Date

________________________________________________

_______________________

Signature of Healthcare Provider/Designated Staff

Date

South Carolina Department of Health and Environmental Control

DHEC 1231 (Rev. 7/2011)

Insured Eligibility Form -South Carolina State Vaccine Program