UNINSURED AND UNDERINSURED ADULT VACCINE (UUAV) PROGRAM
Patient Eligibility Screening Record Adults 19 Years of Age or
Older
*For sites enrolled in the Uninsured and Underinsured Adult Vaccine (UUAV) program.
Providers are required to screen at each visit; however, this same record may be used for all subsequent visits as
long as the patient’s eligibility status has not changed. Retain this record (or equivalent paper or electronic
record) for three years following the date(s) of vaccine administration.
Subsequent visits: Date/initial box if response has not changed.
Screening date:
Patient:
Birth date:
Provider:
The following vaccines are provided by the UUAV program for uninsured and underinsured adults:
▪ Hepatitis A (Havrix)
▪ Hepatitis B (Engerix and
Recombivax)
▪ HPV (Gardasil 9)
▪ Influenza (IIV)
▪ MenB (Bexsero and
Trumenba)
▪ MCV4 (Menactra and
Menveo)
▪ MMR (MMRII)
▪ PCV13 (Prevnar 13)
▪
▪
▪
▪
▪
PPSV23 (Pneumovax)
Td (generic and Tenivac)
Tdap (Adacel and Boostrix)
Varicella (Varivax)
Zoster (Zostavax)
Patient has private insurance that covers immunizations (not eligible)
Patient is a Minnesota Health Care Program (MHCP*) enrollee (not eligible)
*MHCP: Minnesota Health Care Program (Medical Assistance (MA) or MinnesotaCare)
Patient is on Medicare (eligibility varies)
Patient should check which type of coverage they have and if specific vaccines are covered. Those not
covered by Medicare would be eligible for UUAV (underinsured).
Patient is uninsured (eligible)
Patient’s insurance will not pay for vaccination (eligibility varies)
Underinsured: Patients with insurance that does not cover vaccines, that covers only selected vaccines
(eligible for non-covered vaccines only), or that caps prevention services (eligible after cap is reached).
UUAV Program
P.O. Box 64975
St. Paul, MN 55164-0975
Phone: 651-201-5522 or 1-800-657-3970
Email: [email protected]
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