Eligibility Screening Record

New York State Department of Health
Immunization Program
New York Vaccines for Children Program

Eligibility Screening Record

New York State Department of Health Immunization Program New York Vaccines for Children Program

Patient Information
Provider Name
HEALTH CARE PROVIDER: A record of eligibility of all children who receive Vaccines for Children or Child Health Plus B vaccine must be kept in the healthcare provider's office. The record may be completed by the parent, guardian, individual of record, or healthcare provider.The same record may be used for subsequent visits as long as the child's eligibility status has not changed. A new record must be completed if there is a change in eligibility status. While verification of eligibility status is not required, the provider must retain this or a similar record (paper or electronic) for each child receiving vaccines.
Last Name*
First Name*
Middle Name
Parent/Guardian Information
Last Name*
First Name*
Middle Name
Date of Screening
MM
DD
YYYY
Date of Birth
MM
DD
YYYY
Eligibility
Place an X next to the category that shows the child's eligibility (up to their 19th birthday) to receive publicly purchased vaccine in New York.
The Child Is:*
- Medicaid/Medicaid Managed Care enrolled – Check here if patient is enrolled in Medicaid or a Medicaid Managed Care Plan.
- Uninsured/no insurance – Check here if the patient does not have any health insurance.
- American Indian/Alaskan Native – Check here if the patient is American Indian/Alaskan Native. American Indian/Alaskan Native is defined as any individual who (1) is a member of a tribe, band, or other group of Indians including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant in the first or second degree, or any such member, or (2) is an Eskimo or Aleut or other Alaskan Native or (3) is considered by the Secretary of the Interior to be an Indian for any purpose.
- Underinsured – Check here if the patient is underinsured. Children who have health insurance that does not include vaccines are underinsured. Children with health insurance that reimburses for immunizations are not eligible even if the insurance company requires a high deductible, co-payment, or covers only part of the cost of vaccine.
- Not eligible (insurance covers immunizations) – Check here if the patient has insurance that includes vaccines/immunizations. This child is NOT ELIGIBLE to receive VFC/CHPlus B vaccine.
Phone
This field is for validation purposes and should be left unchanged.

Jamestown Office

Randolph Office

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Eligibility Screening Record

Eligibility Screening Record

Patient Information

Parent/Guardian Information

Eligibility

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