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:
ddress:
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/
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
NFECTIOUS DISEASE SCREENING?
YES NO - DONE BY:
MEDICAL HM
PACKET: Y N
CLERK
NITIALS:
$___________TOTAL PAID BY CC CASH CHECK
