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VFC Eligibility Screening Tally Sheet

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									                                        VFC Eligibility Screening Tally Sheet
                                                        2009

     The reviewer must conduct a chart review of 30 records (or all records if <30 total for 0-18 years of age in
     clinic) to verify that this practice is screening for VFC eligibility and maintaining eligibility records.
Record   Patient        Medicaid      Underinsured        Uninsured     American                  Not         No Record
Number   Identifier                   (FQHC/RHC                         Indian/Alaska             VFC         of
                                      only)                             Native                    Eligible    Screening
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

     Is the clinic screening for VFC eligibility?          ‫ ‮‬Yes    No

     If yes, what is the VFC screening coverage in this      Maximum‫‮‬Number‫‮‬of‫“‮‬No‫‮‬Record‫‮‬of‫‮‬Screening”‫‮‬
     clinic/practice? (Circle the correct percentage)        Allowed
     VFC screening coverage of 100%                          0
     VFC screening coverage of at least 95%                  1
     VFC screening coverage at least 90%                     3
     VFC screening coverage below 90%                        4 or more


     The eligibility screening percentage indicated on this form must be recorded on question 29 of the
     “2009 VFC Provider Site Visit Questionnaire”.


     Attachment A for policy 2.2: Calculating a Provider’s VFC-Eligibility Screening Percentage

								
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