Health and Welfare Fee (Childhood Vaccinations) Assessment Request 2026

Get Form
Health and Welfare Fee (Childhood Vaccinations) Assessment Request Preview on Page 1

Here's how it works

01. Edit your form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Health and Welfare Fee (Childhood Vaccinations) Assessment Request

Form edit decoration
9.5
Ease of Setup
DocHub User Ratings on G2
9.0
Ease of Use
DocHub User Ratings on G2
  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by selecting your filing status under 'FILLING AS'. Choose between Insurer, Exempt Insurer, or TPA. If you select 'Exempt Insurer', provide a brief explanation in the designated field.
  3. In the 'REPORTING ENTITY' section, fill in your entity name, street address, city, state, zip code, contact person’s name, phone number, and email address. Ensure that the email provided is suitable for receiving invoices.
  4. Next, report the total number of insured or enrolled lives in Connecticut as of May 1st, 2021. Make sure this number reflects only those covered under specified insurance types. If there are none, indicate 'NONE'.
  5. Complete the 'CERTIFICATION' section by signing and printing your name and title. Ensure that you are authorized to certify this report on behalf of your company.
  6. Finally, submit your completed form electronically via email to cid.vax@ct.gov or mail it to the Connecticut Insurance Department at the provided address.

Start using our platform today to streamline your document editing and submission process for free!

See more Health and Welfare Fee (Childhood Vaccinations) Assessment Request versions

We've got more versions of the Health and Welfare Fee (Childhood Vaccinations) Assessment Request form. Select the right Health and Welfare Fee (Childhood Vaccinations) Assessment Request version from the list and start editing it straight away!
Versions Form popularity Fillable & printable
2021 4.8 Satisfied (122 Votes)
2019 4.2 Satisfied (72 Votes)
be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
Contact us
Compare the childs immunization record with the recommended immunization schedule. Decide whether the child has had all the immunizations recommended for the childs age. On the recording form, check all immunizations the child has already received. Write the date of the immunization the child received most recently.
You can request a copy from the school nurse or administration. State Immunization Registry: Many states have immunization registries where vaccination records are maintained. You can check with your states health department or visit their website for information on how to access these records.
Payments from private insurance and Medicaid vary widely and often fail to cover the full cost of administering vaccines. The federal governments Vaccines for Children program provides free vaccines but no payment for the associated costs.
Full assessment of a vaccine consists of a scientific evaluation of documentary evidence for quality, safety and efficacy.