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
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
Signature of Healthcare Provider/Designated Staff
South Carolina Department of Health and Environmental Control
DHEC 1231 (Rev. 7/2011)


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