Get the free VFC Eligibility Screening Form

A form used by Federally Qualified Health Centers to determine a child's eligibility for the Vaccines for Children program, ensuring access to vaccinations for eligible children under 19.

How to fill out vfc eligibility screening form

How to fill out VFC Eligibility Screening Form

1. Obtain the VFC Eligibility Screening Form from your healthcare provider or the official website.
2. Begin by filling out the child's basic information including name, date of birth, and other identifying details.
3. Indicate the child's insurance status, specifying whether they are uninsured, Medicaid-eligible, or underinsured.
4. Answer questions regarding the child's eligibility based on their household income and family size.
5. Sign and date the form to certify that the information provided is accurate.
6. Submit the completed form to your healthcare provider for evaluation.

Who needs VFC Eligibility Screening Form?

1. Children who are eligible for vaccinations provided through the Vaccines for Children (VFC) program.
2. Families who are uninsured or underinsured children.
3. Children enrolled in Medicaid or those who are Native American or Alaska Native.

People Also Ask about

What are the requirements for VFC vaccine documentation?

In ance with federal law, VFC providers must maintain immunization records that include ALL of the following elements: (1) name of vaccine administered; (2) date vaccine was administered; (3) date VIS was given; (4) publication date of VIS; (5) name of vaccine manufacturer; (6) vaccine lot number; (7) name and

What is required documentation when giving a vaccine?

By law, the following information must be documented on the patient's paper or electronic medical record (or on a permanent office log): The vaccine manufacturer. The lot number of the vaccine. The date the vaccine is administered.

When should screening for VFC eligibility be conducted?

Children ages 18 years or younger who are enrolled in a Medicaid program or are eligible for Medicaid can receive VFC Program benefits. However, children who are enrolled in a separate CHIP program are considered insured and do not qualify for VFC Program benefits.

What are the requirements for meaningful use documentation?

To fulfill the requirements for Meaningful Use, eligible professionals must successfully complete the 3 main components of the program: 1) use certified EHR, 2) meet core and menu set objectives, and 3) report clinical quality measures.

What are the requirements for VFC documentation?

In ance with federal law, VFC providers must maintain immunization records that include ALL of the following elements: (1) name of vaccine administered; (2) date vaccine was administered; (3) date VIS was given; (4) publication date of VIS; (5) name of vaccine manufacturer; (6) vaccine lot number; (7) name and

Who is eligible for the VFC Program?

The Patient Eligibility Screening Record provides documentation to show VFC vaccines are being administered to VFC eligible children. Instructions for use: 1) The Patient Eligibility Screening Record must be completed on the initial visit for each patient receiving vaccines provided by the VFC Program.

For pdfFiller’s FAQs

What is VFC Eligibility Screening Form?

The VFC Eligibility Screening Form is a document used to determine the eligibility of children for the Vaccines for Children (VFC) program, which provides free vaccines to eligible children.

Who is required to file VFC Eligibility Screening Form?

Providers administering VFC vaccines must file the VFC Eligibility Screening Form for children who are to receive vaccines through the VFC program.

How to fill out VFC Eligibility Screening Form?

To fill out the VFC Eligibility Screening Form, one must collect relevant information about the child's insurance status, household income, and eligibility categories, then complete the form based on that information.

What is the purpose of VFC Eligibility Screening Form?

The purpose of the VFC Eligibility Screening Form is to ensure that vaccine resources are appropriately allocated to children who meet the eligibility requirements for the VFC program.

What information must be reported on VFC Eligibility Screening Form?

The VFC Eligibility Screening Form must report the child's name, date of birth, insurance information, the number of people in the household, household income, and eligibility category.