Revised: 05/27/2020
COLLIN COUNTY HEALTH CARE SERVICES ELIGIBILITY SCREENING APPLICATION--PLEASE PRINT LEGIBLY
PATIENT INFORMATION
Last Name: First Name: Middle Name:
Date of Birth: / /
MONTH DAY YEAR
Gender:
Male Female Driver’s License or ID#:
Social Security #: Home Phone: Cell Phone:
A
ddress:
A
pt #: City:
State: Zip Code: County: Mother’s Maiden Name:
Patient’s Marital Status: Annulled Divorced Domestic Partner Living Together Married Separated Single Widowed
Ethnicity: Alaskan Native/American Indian (SEE BELOW) White Black / African American Pacific Islander Asian Hispanic/Latino Other
Does the patient have a primary physician (medical home)? Yes No Is the patient a Veteran? Yes No
If the patient is under 18 years list name of parent/
g
uardian: __________________________ __________________________
(Parent/Guardian Last Name) (Parent/Guardian First Name)
TEXAS VACCINES FOR CHILDREN (TVFC) ELIGIBILITY —
I DECLARE THE PATIENT IS:
HOUSEHOLD INFORMATION /
TVFC PROGRAM FEES
Uninsured: has no health insurance How many people live in the household?______
Medicaid Enrolled: Medicaid Number_________________
Eligibility Date:______/_____/_____
Monthly Income
VFC Vaccine
Administration Fee
Chip Enrolled: Chip Number:________________________
Eligibility Date: ______/_____/_____
$0 - $1,335 No Charge
American Indian or Alaskan Native $1,336 - $2,025 $5 Each Vaccine
Underinsured: patient’s insurance only covers selected vaccines. $2,026 - $2,715 $10 Each Vaccine
Underinsured: patient has commercial/private health insurance,
but coverage doesn’t include vaccines
$2,715+ $14 Each Vaccine
ADULT SAFETY NET (ASN) ELIGIBILITY— I DECLARE THE PATIENT IS: ASN PROGRAM FEES
Uninsured: has no health insurance
$20 Each Vaccine (ASN Vaccine Administration Fee)
PRIVATE PAY ELIGIBILITY— I DECLARE THE PATIENT IS: PRIVATE PAY FEES
Insured: patient’s insurance covers vaccines. Policy/Subscriber
#:___________ Group #:_________
PRICES AND AVAILABILITY VARY,
SEE FRONT DESK STAFF MEMBER FOR ASSISTANCE
ACKNOWLEDGEMENTS
By signing this form, the applicant or legally authorized representative, is authorizing CCHCS or its authorized representative, to submit a
claim for reimbursement and collect payment for any benefit, service or assistance that was received. The patient/parent/guardian, CCHCS
(or authorized representative), as applicable, will submit the claim and collect payment from any private or group health insurance
company, Medicaid, Medicare or any health plan providing coverage to the applicant. The statement I have made, including my answers to
all questions, are true and correct to the best of my knowledge and belief. I agree to give eligibility staff any information necessary to
prove statements about the applicant’s eligibility. I understand giving false information could result in disqualification and repayment.
I understand that as part of the provisions of healthcare services, Collin County creates and maintains health records and other information
describing, among other things, my health and medical history, symptoms, examination and test results, diagnoses, treatment, and any
plans for future care of treatment.
I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain
health information. I understand that Collin County reserves the right to change its notice and practices with regard to the use and
disclosure of health information. I understand that I have the right to request restrictions as to how my health information may be used or
disclosed for treatment, payment of healthcare operations, but that Collin County is not required to agree to the requested restrictions.
Print Name of Person who completed
application (matches ID)
Signature of Person who
completed application
Relationship to Patient Date
/ /
FOR OFFICE USE ONLY—VACCINATIONS REQUESTED FOR OFFICE USE ONLY—PAYMENT DETAILS
PP
VACCINES
ASN
VACCINES
VFC
VACCINES
I
NFECTIOUS DISEASE SCREENING?
YES NO - DONE BY:
MEDICAL HM
PACKET: Y N
CLERK
I
NITIALS:
$___________TOTAL PAID BY CC CASH CHECK
Revised: 05/27/2020
CCHCS HEALTH HISTORY & SCREENING CHECKLIST FOR CONTRAINDICATIONS TO VACCINES
PERSON RECEIVING VACCINATIONS (PATIENT) NAME DATE OF BIRTH
/ /
MONTH DAY YEAR
Is the patient receiving vaccinations today for travel
purposes?
Yes
No Comments:
THE FOLLOWING QUESTIONS WILL HELP US DETERMINE WHICH VACCINES THE PERSON RECEIVING VACCINATIONS MAY
BE GIVEN TODAY. IF YOU ANSWER “YES” TO ANY QUESTION, IT DOES NOT NECESSARILY MEAN THAT THE PERSON
RECEIVING VACCINES SHOULD NOT BE VACCINATED. IT JUST MEANS ADDITIONAL QUESTIONS MAY BE REQUIRED. IF A
QUESTION IS NOT CLEAR, PLEASE DISCUSS WITH YOUR HEALTHCARE PROVIDER.
1. Is the patient sick today? Yes No Comments:
2. Does the patient have allergies to medications,
food, a vaccine component, or latex?
Yes
No Comments:
3. Has the patient had a serious reaction to a vaccine in
the past?
Yes
No Comments:
4. If the patient is of child bearing age, when was the
first day of last menstrual period?
/ / N/A Comments:
5. Is the patient pregnant or is there a chance they
could become pregnant during the next month?
Yes No Comments:
6. Does the patient have a health problem with lung,
heart, kidney or metabolic disease (e.g. diabetes),
asthma, or a blood disorder?
Yes
No Comments:
7. Is the patient on long-term aspirin therapy? Yes No Comments:
8. Has the person receiving vaccinations been told that
they had wheezing or asthma in the past 12 months?
Yes
No Comments:
9. Has the patient ever been told or had intussusception
(bowel obstruction)?
Yes
No Comments:
10. Has the patient ever had a seizure, brain, other
nervous system problem (e.g. Guillain-Barre
Syndrome), or child, sibling, or parent who has had a
seizure?
Yes
No Comments:
11. Does the patient have cancer, leukemia, HIV/AIDS,
or any other immune system problem?
Yes No Comments:
12. In the past 3 months has the patient taken
medications that weaken their immune system, such
as cortisone, prednisone, other steroids, or
anticancer drugs, or had radiation treatments?
Yes
No Comments:
13. In the past year, has the patient received a
transfusion of blood or blood products, or been given
immune (gamma) globulin or antiviral drug?
Yes
No Comments:
14. Has the patient received any vaccinations in the past
4 weeks?
Yes
No Comments:
15. Has the patient had the Chicken Pox Disease? Yes No If yes, what age?:
For all women of child bearing age: By signing below I acknowledge and understand that if I receive any live virus vaccine
during my visit that I should practice birth control of choice for the next four weeks after receiving any live vaccine.
The statements I have made, including my answers to all questions, are true and correct to the best of my knowledge and
belief. I understand that giving false information could result in serious injury or even death. I acknowledge and agree
that signing this screening checklist for contraindications to vaccines is a voluntary act on my part and that I have signed
this document of my own free will and act.
Print Name of Person who
completed application
Signature of Person who
completed application
Relationship to Patient Date
/ /
FOR OFFICE USE ONLY
Form Reviewed By Date
/ /