Get Patient Eligibility Screening Record - Ahwatukee Pediatrics

This guide provides comprehensive instructions on how to accurately complete the Patient Eligibility Screening Record for Ahwatukee Pediatrics online. Following these steps will ensure that necessary information is gathered for your child’s eligibility for the Vaccines for Children Program.

Follow the steps to accurately complete the form

1. Click ‘Get Form’ button to access the Patient Eligibility Screening Record and open it in the designated editor.
2. Enter the date at the top of the form to document when the record is completed.
3. Fill in the child's last name, first name, and middle initial in the designated fields for proper identification.
4. Input the child's date of birth accurately to confirm their eligibility for the VFC program.
5. Provide the name of the parent, guardian, or individual of record in the specified section, ensuring that all details are clear.
6. Write the name of the healthcare provider in the appropriate field to verify involvement in care.
7. Mark only one of the boxes provided to indicate why the child qualifies for vaccination through the VFC program, based on the criteria given.
8. If applicable, check the box indicating whether the child has health insurance that covers vaccines.
9. Review all information for accuracy before signing the form, then provide your signature and the date to validate the record.
10. Once completed, save your changes, and select an option to download, print, or share the completed form as needed.

Take action now and complete the Patient Eligibility Screening Record online to ensure your child's access to necessary vaccinations.