View
6
Download
0
Category
Preview:
Citation preview
New Patient History FORM #: PEDS 110
Name: _______________________________ Date of Birth: ____________________ Today’s Date________________
BIRTH HISTORY
Was your child born Full-term or Preterm? _______________ If Pre-term, how many weeks gestation?______
Were there any complications during birth or in the nursery? ___________________________________________
Birth Weight ___ lb. ___oz. Hospital __________________ City_____________ State ______
Type of Delivery: □ Vaginal □ C-section Hearing Screen: □ Passed □ Failed Males Circumcised □ Yes □ No
CHILD’S HISTORY
Do you consider your child to be in good health? □ Yes □ No □ Unsure Explain:________________________________
Does your child have any serious illnesses or □ Yes □ No □ Unsure Explain:________________________________
medical conditions?
Has your child had any surgeries? □ Yes □ No □ Unsure Explain:________________________________
Has your child ever been hospitalized? □ Yes □ No □ Unsure Explain:________________________________
Is your child allergic to any medications or food? □ Yes □ No □ Unsure Explain:________________________________
Please list any medications your child is currently taking: ____________________________________________________
Are your child’s immunizations up to date? □ Yes □ No □ Unsure Explain:________________________________
Please list any place your child has had vaccines: __________________________________________________________
FAMILY HISTORY
Have any family members (parents, grandparents, siblings, aunts and uncles of your child) had the following?
Hypertension □ Yes □ No Diabetes □ Yes □ No Heart disease □ Yes □ No
Cancer □ Yes □ No Asthma □ Yes □ No Allergies □ Yes □ No
Eczema □ Yes □ No Anemia □ Yes □ No Seizures □ Yes □ No
Liver Disease □ Yes □ No Kidney disease □ Yes □ No Substance abuse□ Yes □ No
HIV/AIDS □ Yes □ No Heart Attack (before the age of 55 years old) □ Yes □ No
If you answered yes to any of the above, or there is an additional problem not listed, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Historial de Nuevo Paciente FORM #: PEDS 110
Nombre del Paciente: __________________________ Fecha de Nacimiento: ________ Fecha de hoy_________
Historial del Nacimiento
Embarazo completo de 9 meses o prematuro? _______________ Si prematuro a las cuantas semanas?______
El nino tuvo algun problema de recien nacido? ___________________________________________
Peso de nacimiento ___ lb. ___oz. En que hospital __________________ Ciudad_____________ Estado ______
Tipo de entrega: □ Vaginal □ Cesarea Examen de audio: □ Pasado □ Fracasado
Niños circumcision □ Si □ No
Historial de Nino/a
Su nino esta en buena salud? □ Si □ No □ No se Explicar:________________________________
Tiene su hijo alguna enfermedad grave o □ Si □ No □ No se Explicar:________________________________
condicion medicas?
Ha tiendo su hijo alguna cirugia? □ Si □ No □ No se Explicar:_________________________________
Su hijo ha sido hospitalizado? □ Si □ No □ No se Explicar:_________________________________
Alergias a los medicamentos o alimentos? □ Si □ No □ No se Explicar:__________________________________
Por favor escribe cualquier medicamento que su hijo este tomando: ________________________________________
Vacunas estan al corriente? □ Si □ No □ No se Explicar:__________________________________
Por favor indique los lugares donde se han recivido vacunas: _____________________________________________
Historial de Familia
Algún familiar (padres, abuelos, hermanos, tias o tios) de tu nino/a an tiendo lo siguiente?
hipertensiòn □ Si □ No diabetes □ Si □ No enfermedad corazòn □ Si □ No
cancer □ Si □ No asma □ Si □ No alergias □ Si □ No
eczema □ Si □ No anemia □ Si □ No convulsiones □ Si □ No
enfermedad hepatica □ Si □ No HIV/AIDS □ Si □ No abuso de sustancias □ Si □ No
enfermedad renal □ Si □ No Ataques al Corazon antes de la edad de 55 anos □ Si □ No
Si ha respondido si a las preguntas anteriores o hay un problema adicional que no este en las lista, explique:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Patient Information Sheet FORM #: PEDS 111
PATIENT (CHILD) INFORMATION
Name
Address
City, State, Zip
Phone ( ) County
Birthdate Sex □ Male □ Female
Ethnicity □ Hispanic or Latino □ Not Hispanic or Latino □ Unknown
Race □ White □ Black □ Hawaiian Native □ Asian □ Unknown
PARENTAL/GUARDIAN BILLING INFORMATION
MOTHER’S INFORMATION
FATHER’S INFORMATION
LEGAL GUARDIAN’S INFORMATION
Name Address City, State, Zip Primary Phone Cell Phone Social Security # Date of Birth Employer Occupation Work Phone Email Address
Guarantor’s Primary language: □ English □ Spanish □ Other_________________________
With whom does the patient reside? □ Both parents □ Mother □ Father □ Legal Guardian
□Other _________________________
PLEASE LIST ALL SIBLINGS THAT COME TO THIS PRACTICE
Name ________________________________ Birthdate_______ Name__________________________ Birthdate____________
Name_________________________________ Birthdate_______ Name__________________________Birthdate____________
EMERGENCY CONTACT INFORMATION
Name (someone who can be contacted if we cannot reach a parent/guardian) Phone Relationship to Patient
I hereby authorize Peds Care, P.C., its physicians and staff, to render appropriate medical care to my dependent child listed above.
Parent/Guardian: _____________________________________________ Date ______________________________________________________
Hoja De Informacion Del Paciente FORM #: PEDS 111
Informacion Del Paciente (Niño, Niña)
Nombre del Niño(A)
Direccion
Ciudad, Estado, Zip Code
Telefono Condado
Fecha de Nacimiento: □ Masculino □ Femenino
Ethnicity □ Hispano or Latino □ No Hispano o Latino □ No Sabe
Raza □ Blanco □ Asiatico □ Negro □ Nativo de Hawai □ No Sabe
INFORACION DE PERSONA RESPONSIBLE A LA FACTURA
INFORMACION DE MADRE
INFORMACION DE PADRE
INFORMACION DE GUARDIAN
Nombre Direccion Ciudad, Estado, Zip Code Telefono de Casa Telefono de Cellular De Segruro Social Fecha de Nacimiento Empleador Ocupacion Telefono de Trabajo Correo Electronico
Lenguaje de preferencia de garante: □ Espanol □ Ingles □ Otro_________________________
Con quien vive el paciente? □ Ambos el padre, la madre □ Solo la madre □ Solo el padre □ El tutor legal
□ Otro _________________________
Por Favor hacer una lista de todo el hermano quien venir a este oficina
Nombre ______________________ Fecha de nacimiento__________ Nombre__________________ Fecha de nacimiento______
Nombre ______________________ Fecha de nacimiento__________ Nombre__________________ Fecha de nacimiento______
CONTACTO EN CASO DE EMERGENCIA
Por favor poner algun amigo o familiar que pueda responder por usted en caso de no poder ubicarsele
Nombre: Telefono: La Relacion a la paciente:
Yo autorizo a Peds Care, P.C., sus doctors y personal de esta oficina a que apliquen el apropiado cuidado a mi hijo(a) quien es depediente de mi.
Firma de padre/madre/guardian _____________________________________________ Fecha _________________________________________
Patient Insurance Information FORM #: PEDS 112
If you are not the parent/legal guardian please do not sign and see a person at our front desk
Child’s Name__________________________________ Date of Birth_________________
What kind of insurance does your child currently have?
□ No insurance or Self Pay □Applied for Medicaid or Peachcare
□ Medicaid □ Amerigroup □Wellcare □Peachstate □ Caresource
□ Peachcare □ Amerigroup □Wellcare □Peachstate □ Caresource
□ Private □ Other__________________________________________
What provider is listed on the patient’s card? _____________________________
Please present Medicaid or Peachcare Care at every visit
Private Insurance Information
Primary Secondary
Insurance Company_________________________ Insurance Company______________________
Insured (Employee)_________________________ Insured (Employee)______________________
Birthdate________________ SSN______________ Birthdate_____________ SSN______________
Relationship to patient_______________________ Relationship to patient____________________
Employer_______________ Group#____________ Employer________________Group#_________
ID#_________________ Effective Date__________ ID#______________ Effective Date___________
Important Information
Please initial that you have read the following
___ Preventive Care Plus Problem Oriented: if your child is here for a preventive care visit, and have significant new symptoms or
worsening of an existing problem, your provider may be able to address both at today’s visit (time permitting). Your insurance will
be billed both a preventive care code and an evaluation and management (E&M) code. In some cases, insurance companies will not
pay for both visits provided by the same provider on the same day. You are responsible for any copayment or payment for any
services denied by your insurance company unless specifically addressed in a participating provider contract with the insurance.
___ I authorize Peds Care, P.C. to release to my insurance company or its agents any information needed to process insurance claims
and/or determine benefits payable for related services. I request that payment of insurance benefits be made on behalf of my
dependent to Peds Care, P.C. for any services furnished to the dependent provider.
____________________________________________________________________________________________________________
Signed Date Relationship to Patient
Información del seguro del paciente FORM #: PEDS 112
Si usted no es el padre / tutor legal, por favor no firme y vea a una persona en nuestra recepción
Nombre__________________________________ Fecha de Nacimiento_________________
Qué tipo de seguro tiene actualmente su hijo?
□ Sin seguro ni autopago □ Medicaid solicitado or Peachcare
□ Medicaid □ Amerigroup □Wellcare □Peachstate □ Caresource
□ Peachcare □ Amerigroup □Wellcare □Peachstate □ Caresource
□ aseguranza privada □ Otro__________________________________________
Qué proveedor esta en la tarjeta del paciente?_____________________________
Presente Medicaid o Peachcare Care en cada visita
Información de seguro privado
Primary Secondary
Insurance Company_________________________ Insurance Company______________________
Insured (Employee)_________________________ insured (Employee)______________________
Birthdate________________ SSN______________ Birthdate_____________ SSN______________
Relationship to patient_______________________ Relationship to patient____________________
Employer_______________ Group#____________ Employer________________Group#_________
ID#_________________ Effective Date__________ ID#______________ Effective Date___________
Información importante
Por favor escribe iniciales que ha leído lo siguiente
___ Atención cuidado preventivo y orientador del problema : si su hijo está aquí para una visita de atención preventiva
y tiene nuevos síntomas significativos o empeoramiento de un problema existente, su proveedor podrá abordar ambos
en la visita de hoy (si el tiempo lo permite). Su seguro recibirá un código de atención preventiva y un código de
evaluación y gestión (E & M). En algunos casos, las compañías de seguros no pagarán las dos visitas provistas por el
mismo proveedor el mismo día. Usted es responsable de cualquier copago o pago por cualquier servicio denegado por
su compañía de seguros a menos que se trate específicamente en un contrato de proveedor participante con el seguro.
___ Yo Autorizo a Peds Care, P.C. a compartir a mi compañía de aseguranza o a sus agentes toda la información
necesaria para procesar los reclamos de seguro y / o determinar los beneficios pagaderos por los servicios relacionados.
Solicito que el pago de los beneficios del seguro se realice en nombre de mi dependiente a Peds Care, P.C. para cualquier
servicio proporcionado al proveedor dependiente.
_____________________________________________________________________________________
Firma Fecha Relación con el paciente
Consent to Treat FORM #: PEDS 113
Please be advised that only a parent or legal guardian should complete this form. If you are not the
parent/legal guardian, please leave this form blank. Thank you.
Child’s Name: _______________________________ Birthdate ______________
Please list any individuals below that have your consent to authorize medical treatment, approve vaccines, pick up
prescriptions, speak to staff over the phone in regards to your child, or anything else deemed necessary by the health
care provider.
_______________________________________ ____________________________________
Name Relationship to Child
_______________________________________ ____________________________________
Name Relationship to Child
_______________________________________ ____________________________________
Name Relationship to Child
_______________________________________ ____________________________________
Parent/Guardian Signature Date
Communication Consent
In compliance with federal law, it is the Policy of Peds Care, P.C. to NOT leave confidential information on answering
machines, voice mail, e-mail, or with unauthorized individuals who are not listed on the consent to treat form. If you
would prefer that we leave this information on a designated voicemail in the instance that we are unable to reach you,
please specify the phone number where we can leave a detailed voicemail.
______________________________ _________________________ ________________________________
Name Phone Number Relationship to Child
______________________________ _________________________ ________________________________
Name Phone Number Relationship to Child
______________________________ _________________________ ________________________________
Name Phone Number Relationship to Child
_______________________________________ ____________________________________
Parent/Guardian Signature Date
Consentimiento para tartar FORM #: PEDS 113
Tenga en cuenta que solo un padre o tutor legal debe completar este formulario. Si no es el padre / tutor legal, deje este formulario
en blanco. Gracias.
Nombre: _______________________________ Fecha de Nacimiento:______________
Indique las personas a continuación que cuenten con su consentimiento para autorizar el tratamiento médico, aprobar vacunas, retirar
recetas, hablar con el personal por teléfono con respecto a su hijo o cualquier otra cosa que el proveedor de atención médica considere
necesaria.
_____________________________________ ____________________________________
Nombre Relación con el niño
Nombre Relación con el niño
____________________________________
Nombre Relación con el niño
_______________________________________ ____________________________________
Firma del padre/tutor Fecha
Consentimiento de comunicación
De conformidad con la ley federal, es la Política de Peds Care, P.C. NO dejar información confidencial en contestadores automáticos,
correo de voz, correo electrónico o personas no autorizadas que no figuran en el formulario de consentimiento para tratar. Si prefiere
que dejemos esta información en un correo de voz designado en el caso de que no podamos comunicarnos con usted, especifique el
número de teléfono donde podemos dejar un mensaje de voz detallado.
______________________________ _________________________ ________________________________
Nombre Número de teléfono Relación con el niño
______________________________ _________________________ ________________________________
Nombre Número de teléfono Relación con el niño
______________________________ _________________________ ________________________________
Nombre Número de teléfono Relación con el niño
_______________________________________ ____________________________________
Firma del padre/tutor Fecha
FORM #: PEDS 114 ACCT #
HIPAA Privacy Rule
Receipt of Notice of Privacy Practices
Written Acknowledgement Form
Acknowledgement of receipt of Information Practices Notice (§164.520(a))
I (Childs Name) _______________________________, understand that as part of my healthcare, this
facility originates and maintains health records describing my health history, symptoms, examination
and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I
have been provided with and understand that this facility’s Notice of Privacy Practices provides a
complete description of the uses and disclosures of my health information. I understand that:
• I have the right to review this facility ‘s Notice of Privacy Practices prior to signing this
acknowledgement
• This facility reserves the right to change their Notice of Privacy Practices and prior to
implementation of this will mail a copy of any revised notice to the address I've provided if
requested.
Signature of Individual or Legal Representative Witness ___________________________________
Printed Name of Individual or Legal Representative ______________________________________
Date: ________________
FOR OFFICE USE ONLY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it
could not be obtained because:
Individual refused to sign
Communication barrier prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
Others (please specify)
__________________________________________________________________
FORM #: PEDS 114 ACCT #
Regla de Privacidad HIPAA
Recibo de Noticia de Practicas Privadas
Forma de Reconocimiento Escrita
Reconocimiento de recibo de Noticias de Practicas de Información (§164.520(a))
Yo, ______________________________________; entiendo que, como parte de mi cuidado de salud,
esta instalación origina y mantiene registros de salud describiendo mi historial de salud, síntomas,
resultados de pruebas y exámenes, diagnósticos, tratamientos y cualquier tratamiento o cuidado de
salud futuro. Reconozco que se me ha provisto con, y he entendido, que la Noticia de Practicas Privadas
de estas instalaciones proveen una descripción completa de los usos y divulgaciones de mi información
de salud. Entiendo que:
• Tengo el derecho de revisar las Noticias de Practicas Privadas de estas instalaciones antes de
revisar el reconocimiento
• Estas instalaciones se reservan el derecho de cambiar sus Noticias de Practicas Privadas y antes
de la implementación de las mismas enviaran una copia por correo electrónico de cualquier
revisión a la dirección que he provisto, si se me pide.
Firma del Individuo ________________________________________
Nombre Impreso del Individuo ________________________________________
Fecha: _______________
SOLO PARA USO DE OFICINA – FOR OFFICE USE ONLY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it
could not be obtained because:
Individual refused to sign
Communication barrier prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
Others (please specify)
______________________________________________________________________
______________________________________________________________________
FORM #: PEDS 114 ACCT #
Consent and Authorization for Minors FORM #: PEDS 115
If a minor is brought in to Peds Care, P.C. by someone other than the birth parent/custodial parent or
legal guardian, the minor child must be accompanied by a note (“Authorization”). Authorization must
include the date when it was written, name of the patient, name of the person bringing the child, what
the child is being seen for, the birth/custodial parent or legal guardian’s signature and a telephone
number where the birth/custodial parent or legal guardian can be reached.
I, ______________________________, (Circle your relationship to the patient: parent/legal guardian/grandparent)
PRINT YOUR NAME
Give consent for the individual identified below to bring the minor child to the Peds Care, P.C. office for
medical treatment. I hereby authorize the Peds Care, P.C. Pediatric physicians and other personnel, to
render medical care to my minor child in accordance with the Authorization without obtaining
additional consent from me.
___________________________________________ _________/_________/_________
PRINT FULL NAME OF MINOR CHILD (patient) DATE OF BIRTH (patient)
___________________________________________ ____________________________
Print Name of person bringing minor in for the appointment Relationship to Minor
(_____ )__________________________________
Phone number where parent/legal guardian can be reached
_______________________________________ ___________________
Signature of Parent or Legal Guardian Date
Consentimiento y Autorización para Menores FORM #: PEDS 115
Si un menor es traído a Peds Care, P.C. por otra persona que no sea el padre biológico / padre con
custodia o tutor legal, el menor deberá ir acompañado de una nota ("Autorización"). La autorización
debe incluir la fecha en que fue escrita, el nombre del paciente, el nombre de la persona que trae al
niño, para qué se ve al niño, la firma del padre / custodio o tutor legal, y un número de teléfono donde
se puede contactar al padre / madre o tutor legal de nacimiento / custodiaI
Yo, ______________________________,(Circular su relación con el paciente: padre / tutor legal/abuelo)
IMPRIMA SU NOMBRE
Doy consentimiento para que la persona identificada a continuación lleve al menor a Peds Care, P.C.
oficina para tratamiento medico Por la presente autorizo a Peds Care, P.C. Médicos pediátricos y otro
personal, para prestar atención médica a mi hijo menor de acuerdo con la Autorización sin obtener un
consentimiento adicional de mi parte.
___________________________________________ _________/_________/_________
IMPRIMIR NOMBRE COMPLETO DE HIJO MENOR FECHA DE NACIMIENTO (paciente)
___________________________________________ ____________________________
Imprimir Nombre de la persona que trajo a un menor para la cita Relacion con el Menor
(_____ )__________________________________
Número de teléfono donde se puede contactar al padre / tutor legal
_______________________________________ ___________________
Firma del padre o tutor legal Fecha
CONSENT FOR PATIENTS 18 YRS & OLDER- FORM #: PEDS 116
Name: __________________________________ Birthdate ____________
Because you are 18 years of age or older, anyone that you wish to have access to your medical
information must be listed on this document. Whether in person or over the phone, this
individual can schedule office appointments, speak to nurses, pick up prescriptions or other
forms, and/or receive personal information concerning you.
_____________________________________ ______________________________________
Name Relationship to Patient
_____________________________________ ______________________________________
Name Relationship to Patient
_____________________________________ ______________________________________
Name Relationship to Patient
Do you want information regarding sexual health disclosed to these individuals? This includes
screening or treatment for STD’s and/or pregnancy. □ Yes □ No
□ I DO NOT authorize anyone other than myself to access my protected health information for
ANY reason.
If a member of Peds Care, P.C. is unable to reach you at the phone number you have provided,
please select any information that can be left on your voicemail
□ Appointment Reminders □ Lab Results □ Referral Information □ Financial Information
By signing the following, I understand that a written request must be submitted in order to
make changes to, or revoke this authorizaiton.
____________________________________ _______________________________________
Patient Signature Date
____________________________________ _______________________________________
Witness Signature Date
CONSENTIMIENTO PARA PACIENTES MAYORES DE 18 AÑOS FORM #: PEDS 116
Nombre: __________________________________ Fecha de Nacimiento: ____________
Debido a que tiene 18 años de edad o más, cualquier persona que desee tener acceso a su información
médica debe de estar en este documento. Ya sea en persona o por teléfono, esta persona puede
programar citas en la oficina, hablar con enfermeras, recoger recetas u otros formularios y / o recibir
información personal sobre usted.
____________________________________ ______________________________________
Nombre Relacion al Paciente
_____________________________________ ______________________________________
Nombre Relacion al Paciente
_____________________________________ ______________________________________
Nombre Relacion al Paciente
Desea que se de información sobre su salud sexual a estas personas? Esto incluye exámenes de
detección o tratamiento para enfermedades de transmisión sexual y / o embarazo. □ Si □ No
□ YO NO autorizo a nadie más que a mí a acceder a mi información de salud protegida por CUALQUIER
motivo.
Si es miembro de Peds Care, P.C. no puede comunicarse con usted al número de teléfono que ha
proporcionado, seleccione cualquier información que pueda dejarse en su correo de voz
□ Recordatorios de citas □ Resultados de laboratorio □ Información de referencias
□ Información financieras
Al firmar lo siguiente, entiendo que debe enviarse una solicitud por escrito para realizar cambios o
revocar esta autorización.
____________________________________ _______________________________________
Firma del Paciente Fecha
____________________________________ _______________________________________ Firma de testigo
Fecha
State of Georgia Immunization Office
VACCINES FOR CHILDREN (VFC) PROGRAM
Patient Eligibility Screening Record
Date: _________________ Provider/Physician: _________________________ MM/DD/YYYY
The Patient Eligibility Screening Record provides documentation to show VFC vaccines are being administered to VFC eligible children. Definitions VFC Eligible: Child meets eligibility criteria outlined in #4 below. Non-VFC Eligible: Any patient who does not meet VFC criteria or special populations defined by the Georgia
Department of Public Health (DPH) Immunization Program. A child who has health insurance that covers vaccines is considered fully insurance and is not eligible for VFC vaccines. This category also includes high-deductible plans which are also considered fully insured and ineligible for VFC and state supplied vaccine.
Instructions for use: 1) The Patient Eligibility Screening Record must be completed on the initial visit for each patient receiving vaccines
provided by the VFC Program. Subsequent screenings should be documented under the “Screening Updates” portion of the form. The parent/guardian should be asked at each visit if the child’s VFC eligibility status has changed. This form should be kept in the patient’s file for a minimum of 3 years.
2) The Patient Eligibility Screening Record should be maintained in the patient’s file or a central file in your office.
If your billing system captures VFC eligibility, you can document eligibility electronically instead of using the paper form. However, eligibility for any given date of service in history must be researchable and verifiable for that date.
The method of documentation is flexible as long as your office can produce a list of VFC eligible patients if needed.
3) For Medicaid and PeachCare for Kids participants, a copy of the Medicaid or PeachCare for Kids card in the patient’s
medical record serves as appropriate eligibility documentation in place of the Patient Eligibility Screening Record. Things to know regarding PeachCare enrolled patients:
PeachCare enrolled patients are not VFC eligible however, an agreement is in place between the
Department of Public Health and PeachCare which allows doses to be administered to PeachCare enrolled patients from your state supplied vaccine inventory.
Office staff must be able to differentiate between a PeachCare enrolled patient with Medicaid as the payee
vs. a PeachCare enrolled patient with PeachCare as the payee. When Medicaid is the payee, the patient should be indicated as Medicaid covered.
4) Children eligible for Georgia VFC include children birth through 18 years of age who are:
Medicaid Enrolled Uninsured (child has no health insurance coverage) Underinsured (child has insurance that does not cover vaccines, seen in a Federally Qualified Health Center
or Rural Health Center)* American Indian or Alaska Native
*The Georgia Department of Public health has made funding available for state supplied vaccines to be administered to underinsured patients seen in a non-FQHC or RHC. So while these patients are not VFC-eligible, they are eligible for state supplied doses.
Patient Eligibility Screening Record
Vaccines for Children Program
This provider participates in the Vaccines for Children Program (VFC). If you meet the requirements of this program, we can provide your child’s immunizations at a reduced fee. In order to determine eligibility, we must know if your child has insurance that pays for immunizations.
Child: Date of Birth:
Last Name First Name MI MM/DD/YYYY
Parent/Guardian: Last Name First Name MI
INELIGIBLE FOR STATE-SUPPLIED VACCINE (Check if applicable)
The child 18 years of age or younger has insurance that pays for immunizations. (Fully-insured / Private Pay, includes high deductible plans)
ELIGIBLE FOR STATE-SUPPLIED VACCINE This child 18 years of age or younger qualifies for vaccination with state-supplied vaccine because (check only one box):
The child is enrolled in Medicaid
The child is American Indian or Alaska Native
The child does not have health insurance (Not Insured)
The child has health insurance that does not pay for vaccines (Underinsured)
The child is enrolled in PeachCare for Kids
Note to Providers: A record must be kept in the healthcare provider’s office that reflects the status of all children 18 years of age or younger, who receive immunizations with vaccines supplied by state programs. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine.
S C R E E N I N G U P D A T E S
DATE SCREENED
State Supplied Vaccine Eligible
(Check only one category) NOT
ELIGIBLE
PEACHCARE FOR KIDS
MEDICAID ENROLLED
UNINSURED
AMERICAN INDIAN OR
ALASKA NATIVE
UNDER-INSURED
INSURANCE COVERS
VACCINATIONS
Recommended