Insured Eligibility Form -South Carolina State Vaccine Program (Page 2 of 2) in pdf

Insured Eligibility Form -South Carolina State Vaccine Program Page 2

South Carolina STATE Vaccine Program:

Insured Eligibility Form

Instructions for Completing

Purpose:

To provide documentation for non-DHEC healthcare providers enrolled in the South

Carolina STATE Vaccine Program of eligibility for non- VFC eligible children <19 years

of age to receive STATE vaccine, prior to vaccine administration.

General Instructions for Use:

The Insured Eligibility Form is to be completed prior to administration of vaccine(s).

Item-By-Item Instructions:

1. Complete the Child’s Name, Date of Birth, Insurance Company, Policy Number,

and Name and Insurance ID Number of Policy Holder (this section of form may

be completed by parent/guardian/individual of record).

2. Assess child’s eligibility for STATE vaccine and check appropriate box(es), as

applicable.

3. Parent/Guardian/Individual of Record to sign and date form affirming the

information they have provided is accurate and authorizing DHEC to verify

insurance information given.

4. Healthcare provider or healthcare provider staff authorized to assess eligibility

for STATE Vaccine to sign and date form.

Office Mechanics and Filing:

The completed Insured Eligibility Form must be retained for (3) years.

South Carolina Department of Health and Environmental Control

DHEC 1231 (Rev. 7/2011)

Insured Eligibility Form -South Carolina State Vaccine Program Page 2