Patient Eligibility Screening Record - Virginia Department Of Health

Health Department

Vaccines for Children (VFC) Program

Patient Eligibility Screening Record

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 :___________________________________________________________________________________

Last Name

First Name

MI

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

3. Parent/Guardian/Individual of Record:__________________________________________________________________

Last Name

First Name

MI

4. Primary Provider’s Name:___________________________________________________________________________

Last Name

First Name

MI

5. To determine if a child (0 through 18 years of age) is eligible to receive federal vaccine through the VFC and 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 D, E, F or G is marked the child is not eligible for federal VFC vaccine.

Eligible for VFC Vaccine

Not eligible for VFC Vaccine

A

B

C

D

E

F

G

*Has health

Medicaid

No Health

American

**Other

****Adult

insurance that

***Enrolled

Enrolled

Insurance

Indian or

Date

underinsured

un/underinsured

covers

in FAMIS

Alaskan Native

vaccines

*Children who have health insurance that covers vaccine are not eligible to receive federal vaccine purchased with VFC funds. However, if these children may be served

(using State/Section 317 stock) if they are receiving the following vaccines because of and in accordance with Code requirements and/or current agency policy:

DTaP, hepatitis B, Hib, MMR, pneumococcal conjugate, polio, Tdap, HPV and Varicella vaccines.

 As a reminder, HPV vaccine may be administered free of charge only to girls who will be enrolled in the 6th grade as of September, 2007, as well as all other females

who are 11 or 12 years of age.

 Insured children receiving any other vaccines (e.g., hepatitis A, MCV, rotavirus vaccine, or HPV vaccine outside of the guidelines above) should receive chargeable

vaccine.

* *Other underinsured are children that are underinsured but are not eligible to receive federal vaccine purchased with VFC funds because the provider or facility is not a

FQHC/RHC. However, these children may be served if vaccines are provided by the state program to cover these non-VFC eligible children.

***Children enrolled in the Family Access to Medical Insurance Security Plan (FAMIS). These children are considered insured and are not eligible for federal vaccine

purchased with VFC funds. The Virginia Department of Medical Assistance Services (DMAS) provides specific guidance on how FAMIS vaccine is purchased and

administered through participating providers. However, if these children may be served (using State/Section 317 stock) if they are receiving the following vaccines because of

and in accordance with Code requirements and/or current agency policy:

DTaP, hepatitis B, Hib, MMR, pneumococcal conjugate, polio, Tdap, HPV and Varicella vaccines.

 As a reminder, HPV vaccine may be administered free of charge only to girls who will be enrolled in the 6th grade as of September, 2007, as well as all other females

who are 11 or 12 years of age.

 Insured children receiving any other vaccines (e.g., hepatitis A, MCV, rotavirus vaccine, or HPV vaccine outside of the guidelines above) should receive chargeable

vaccine.

****Uninsured and underinsured adults are not eligible to receive federal vaccine purchased with VFC funds. However, they may be served if vaccines are provided by the

state program to cover these non-VFC eligible patients.

8/26/2014