Patient Eligibility Screening Record for State Supplied Vaccines
Vaccines for Children Program (VFC) / West Virginia Children’s
 Insurance Program (WVCHIP)

1.  Today’s Date:   _____/______/_____

2.  Child’s Name: _____________________________________________________________                                                                                                                                 
			      Last Name                                        First                                                  MI

3.  Child’s Date of Birth:  _____/______/_____              	        		

4.  Parent/Guardian/Individual of Record: __________________________________________                                                                                                
                                                                         Last Name                            First                              MI
5.  This child is privately insured and does not qualify for state-supplied vaccines.   9

6.  This child is enrolled in WVCHIP and qualifies for state-supplied vaccine.    9

7.  This child qualifies for immunization through the VFC program because he/she (check only one):
	a) Is enrolled in Medicaid								           9
Or
	b) Does not have health insurance							9 
Or
	c) Is an American Indian or Alaskan Native						9 
Or
	d) Is underinsured (has health insurance that does not pay for vaccinations)*	9
		* Underinsured children must be vaccinated at a FQHC or RHC.

8.  Is your facility a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)?
9   Yes	9 No

9.  Primary Provider’s Name:  ___________________________________________________
					          Last Name			First  	     		MI

A record of all children 18 years of age or younger who receive VFC/WVCHIP program immunizations must be kept in the health care provider’s office.  The record may be completed by the parent, guardian, individual of record, or by the health care provider.  This same record will satisfy the requirements for all subsequent vaccinations, as long as 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.