Texas Vaccines for Children (TVFC) Program

A record of all children 18 years of age or younger who receive immunizations through the Texas Vaccines for Children (TVFC) Program must be kept in the health care provider’s office for a minimum of five (5) years. The record may be completed by the parent, guardian, individual of record, or by the health care provider. TVFC eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure eligibility status for the program. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccines under the TVFC Program.

1. Child's Last Name:

First Name:

MI:

2. Child’s Date of Birth:

3. Parent, Guardian, or 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 TVFC Program, at each immunization encounter or visit, enter the date and mark the appropriate eligibility category. If Column A - F is marked, the child is eligible for the TVFC Program. If column G is marked the child is not eligible for federal VFC vaccine.

Date:

Eligible for VFC Vaccine

A. Medicaid Enrolled

B. No Health Insurance

C. American Indian or Alaskan Native

D. * Underinsured served by FQHC, RHC, or deputized provider

State Eligible

E. ** Other underinsured

F. *** Enrolled in CHIP

Not Eligible

G. Has health insurance that covers vaccines

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

** Other underinsured are children that are underinsured but are not eligible to receive federal vaccine through the TVFC Program because the provider or facility is not an FQHC or an RHC, or a deputized provider. However, these children may be served if vaccines are provided by the state program to cover these non-TVFC-eligible children.

*** Children enrolled in the State of Texas Children’s Health Insurance Program (CHIP). An agreement between the DSHS Immunization Unit and CHIP stipulates that vaccines for eligible CHIP enrollees are purchased through the federal contract.

Date:

Eligible for VFC Vaccine

A. Medicaid Enrolled

B. No Health Insurance

C. American Indian or Alaskan Native

D. * Underinsured served by FQHC, RHC, or deputized provider

State Eligible

E. ** Other underinsured

F. *** Enrolled in CHIP

Not Eligible

G. Has health insurance that covers vaccines

Add more

Medicaid:

Medicaid Number:

Date of Eligibility:

CHIP:

CHIP Number:

Group Number:

Date of Eligibility:

Private Insurance:

Name of Insurer:

Insurer Contact Number:

Insurance Name:

Policy or Subscriber Number:

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