Illinois Department of Public Health
Patient Eligibility Screening Record
Vaccines for Children (VFC) Plus Program
Date
Child's Name
First Last Mi.
Date of Birth
Parent/Guardian/Individual of Record
First Last Mi.
Provider LIVINGSTON COUNTY PUBLIC HEALTH DEPARTMENT
A record must be kept in the health care provider's office that reflects the status of all children 18 years of age or younger who receive immunizations through the VFC Plus Program. The record may be completed by the parent, guardian, individual of record, or by the health care provider. This same record may be used for all subsequent visits as long as the childs' eligibility status has not changed. While verification responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine.
The parent or guardian has stated that this child qualifies for vaccination through the Federal Vaccines for Children (VFC) program because he or she (check only one box):
| A. | Is enrolled in Medicaid | |
| B. | Does not have health insurance | |
| C. | Is American Indian or Alaskan Native |
OR this child does not qualify for vaccination through teh Vaccines for Children (VFC) program (unless the provider is a Federally Qualified Health Center or Rural Health Clinic); however, this child may be provided vaccine through the Illinois Vaccines for Children (VFC) Plus Program because he or she:
|
D. |
Has health insurance that does not pay for vaccines (under insured) |
The above eligibility status information was provided by me to my child's health care provider.
Signature of Parent or Legal Guardian Date
Printed by Authority of the State of Illinois
P.O. 1515144 10m 09/94
IL 482-0893