Dhec 1146 Form – Fill Out and Use This PDF

South Carolina Department of Health and Environmental Control

Vaccines For Children (VFC) Program Patient Eligibility Screening Record Form

Purpose:

The purpose of this form is to provide screening and documentation of the eligibility status at each immunization encounter (visit) for the Vaccines for Children (VFC) program for children 18 years of age or younger, prior to administration of vaccine(s). In addition, screening and documenting eligibility status for the state vaccine eligible child through the South Carolina State Vaccine Program at each immunization

encounter (visit). This form captures the documentation for screening all categories of VFC and non-VFC eligible children seen in the VFC provider’s office during immunization encounters (visits). Screening and Documentation of eligibility statuses is a requirement for all providers

enrolled in the vaccine programs.

General Instructions for Use:

The Vaccines For Children (VFC) Patient Eligibility Screening Record Form will be completed by the parent, guardian, individual of record, or healthcare provider staff prior to administration of vaccine(s) for every immunization encounter (visit).

Item-By-Item Instructions:

1.Complete the Child’s Name, Child’s Date of Birth, Parent/Guardian/ Individual of Record, and Provider’s Name.

2.Assess client’s eligibility for publicly funded vaccine. Record the date of the immunization encounter (visit).

3.After determination of eligibility category, mark in the appropriate column:

Eligible for VFC Vaccine

A.Medicaid- Enrolled (VFC Stock)

B.No Health Insurance (VFC Stock)

C.American Indian or Alaska Native (VFC Stock)

D.1Underinsured, served by FQHC, RHC or deputized provider (VFC Stock)

Not eligible for VFC Vaccine

E. Has health insurance that covers vaccines (Private Stock)

F. 2SC State Underinsured, served by Non-FQHC/RHC (State Stock)

G. 3SC State Insured, Insured Hardship, Vaccine Caps (State Stock)

Office Mechanics and Filing:

Private Provider:

The completed Vaccines For Children (VFC) Patient Eligibility Screening Record Form must be kept for (3) years from most recent “date of immunization visit.”

1Underinsured 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) 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 vaccinate underinsured children.

2SC State Vaccine Program Underinsured: These children are underinsured but are not eligible to receive federal vaccine through the VFC program because the provider or facility is not an FQHC/RHC or a deputized provider. However, these children may be served with state vaccine program vaccine to cover these non-VFC eligible children. Only providers enrolled in the SC State Vaccine Program are eligible to serve this population. You must have SC State Vaccine program vaccine stock prior to seeing this patient population.

3SC State Vaccine Program - Insured Hardship and Vaccine Caps. These children are considered insured and are not eligible for vaccines through the VFC program. However, these children may be served state vaccine program vaccine to cover these non-VFC eligible children. Insured Hardship is defined as “Health Insurance deductible is greater than $250.00 per child or $500.00 per family (Eligible for state vaccine only if the deductible has not been met and the family cannot aff ord to pay for vaccine).” Vaccine Caps is defined as “Insured but coverage capped at certain amount and cap has been exceeded.” The Human Papillomavirus Vaccine is excluded from the SC State

Vaccine Program. Only providers enrolled in the SC State Vaccine Program are eligible to serve this population. You must have SC State Vaccine program vaccine stock prior to seeing this patient population.

DHEC:

File in Patient’s medical record.

DHEC 1146 (REV. 4/2014)

SOUTH CAROLINA DEPARTMENT OF HEALTH & ENVIRONMENTAL CONTROL