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Get Patient Eligibility Screening Form Massachusetts

For Healthier Lives MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH IMMUNIZATION PROGRAM VACCINES FOR CHILDREN PROGRAM VFC Immunize Patient Eligibility Screening Form For use in all Provider Sites except Federally Qualified Community Health Centers Initial screening Child s full name Parent guardian or legal representative s full name Health care provider s full name Check only one box below This child is eligible for immunizations through the federal .

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