NURSING SECTION VFC (Vaccine For Children 18 or Younger) Eligibility Status (GIVE STATE OR VFC VACCINE) Is American Indian or Alaskan Native □ Has Medical Assistance/Medicaid □ Does not have health insurance □ Underinsured (vaccines not covered by health insurance) □ PRIVATE VACCINE (Child or Adult) Not VFC eligible (bill Medica, BCBS, Sanford Health Plan, ND (Adult) Medicaid, Medicare, or Humana) □ Not VFC eligible insurances not billed by Richland County Health Department _______________________________ □ – Client desires to receive and pay for vaccine and receive a bill (name of insurance) □ Client desires to pay for vaccine and declines super bill □ Reported weight (if 18 or younger) ________________ Date Vaccine(s) VIS Date MFG. Lot Exp. Dosage State or to be given Number Date Site Private High Dose 0.25 ml LA RA 08/07/15 SP/GSK IM S P 0.5 ml LT RT IIV4 FOBT SCREENING: INTERESTED: Pneumonia Y N Y N Shingrex Age between 50-75 Colonoscopy in last 10 □ □ □ □ Referred for iFOBT Client refused iFOBT □ □ □ □ Nurses Signature: ______________________________________ Date:__________________ Check #___________ Credit Card Confirmation #_____________ Cash_________ Receipt #_____________ Initials________ 09/18/2018
NURSING SECTION VFC (Vaccine For Children 18 or Younger) Eligibility Status (GIVE STATE OR VFC VACCINE) □ Is American Indian or Alaskan Native □ Has Medical Assistance/Medicaid □ Does not have health insurance □ Underinsured (vaccines not covered by health insurance) PRIVATE VACCINE (Child or Adult) □ Not VFC eligible (bill Medica, BCBS, Sanford Health Plan, ND (Adult) Medicaid, Medicare, or Humana) □ Not VFC eligible – insurances not billed by Richland County Health Department _______________________________ □ Client desires to receive and pay for vaccine and receive a bill (name of insurance) □ Client desires to pay for vaccine and declines super bill Reported weight (if 18 or younger) ________________ Date Vaccine(s) to be given VIS Date MFG. Lot Number Exp. Date Dosage Site State or Private High Dose IIV4 08/07/15 SP/GSK 0.25 ml 0.5 ml LA RA LT RT IM S P FOBT SCREENING: INTERESTED: Pneumonia Y N Y N Shingrex Age between 50-75 □ □ Colonoscopy in last 10 □ □ Referred for iFOBT □ □ Client refused iFOBT □ □ Nurses Signature: ______________________________________ Date:__________________ Check #___________ Credit Card Confirmation #_____________ Cash_________ Receipt #_____________ Initials________ 09/18/2018