Vaccines for Children (VFC Program)

Patient Eligibility Screening Record

Please correct the errors described below.

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 a vaccine. Providers using a similar form (paper-based or electronic) must capture all reporting elements included in this form.

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-D is marked, the child is eligible for the VFC program, if Column E, F or G is marked the child is not eligible for federal VFC vaccine.

Add Additional Category

Add Additional Category

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that not covered by insurance. In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputized provider. The deputized provider must have a written agreement with an FQHC/RHC and the state / local territorial immunization program in order to vaccine underinsured children.

Other underinsured are children that are underinsured but are not eligible to receive federal vaccine through the VFC program because the provider or facility is not a FQHC / RHC or a deputized local health department. Children who are enrolled in separate state Children's Health Insurance Program (CHIP) with Medicaid Title XXI (21) or State Funded coverage are considered insured and are NOT eligible for vaccines through the VFC program.

Your information will be encrypted.