As a service to our patients, our office participates in the Vaccines For Children (VFC) program, which provides vaccines at no charge for those patients who meet the program’s eligibility requirements.* A patient who meets any one of the following requirements is eligible and automatically qualifies for the VFC program: - is enrolled in Medicaid - is enrolled in Children’s Health Insurance Plan (CHIP) - does not have health insurance - is underinsured (has health insurance that DOES NOT pay for vaccines**) - is an American Indian - is an Alaskan Native ** Overseas travelers insurance policy holders (e.g. AIU) are considered underinsured. If your child meets any of the requirements listed above, please complete, sign, and return the TVFC Patient Eligibility Screening Record to our front office staff instead of this disclaimer form. The TVFC Patient Eligibility Screening Record form must be completed and signed for EACH child that is eligible for the VFC program. If your child DOES NOT meet any of the requirements listed above, please sign below and return this disclaimer form to our front office staff. Please be aware that if your child does not meet the VFC requirements and your insurance does not cover the cost of the vaccination(s), you will be responsible for payment. There are four public health clinic locations in the city of Houston that provide all necessary vaccinations for a nominal fee. Please let us know if you need this information. Disclaimer I have read and understand the VFC information above. By signing below, I acknowledge that my child is not qualified for the Texas Vaccine for Children (TVFC) program.
