UUAV Forms and Resources

Forms

• Can I Get Free or Low-cost Shots? (PDF)
  UUAV patient self-screening form to determine eligibility for free or low-cost vaccines for Minnesota residents 19 years of age and older through the UUAV program.
  • Can I Get Free or Low-cost Shots? in Hmong (PDF)
  • Can I Get Free or Low-cost Shots? in Somali (PDF)
  • Can I Get Free or Low-cost Shots? in Spanish (PDF)
• Patient Eligibility Screening Record (PDF)
  Provider screening record for patient UUAV program eligibility. This record may be used for all subsequent visits if the patient’s eligibility has not changed.
• Vaccine Management Forms
  Returning nonviable vaccine, vaccine transfer record and the vaccine restitution appeal forms.

Resources

• Dose-Level Eligibility Codes and Minnesota Vaccines for Children (MnVFC) and Uninsured and Underinsured Adult Vaccine (UUAV) Eligibility Status (PDF)
  Providers are encouraged submit MnVFC and UUAV program eligibility status at the vaccine dose-level to MIIC through electronic data submissions.
• Vaccination Clinics Serving Uninsured and Underinsured Adults
  Search for clinics that offer free or low-cost vaccine for qualifying uninsured and underinsured adults.
• Minnesota Department of Health Vaccine Programs (PDF)
  This flyer provides an overview of the two different vaccine programs offered through MDH.