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Click ‘Get Form’ to open the TVFC Program - Vaccine Transfer Authorization Form in the editor.
Begin with Section A, where you will enter the original facility information including the PIN, today's date, and the original facility name along with its delivery address.
If there is a facility name change, proceed to Section B. Enter the new facility name while adhering to character limits and formatting guidelines.
In Section C, provide details for the new signing clinician including their name, title, specialty, email address, medical license number, and Medicaid or NPI number.
For changes in prescribing authorities, navigate to Section D. Add or remove names as necessary along with their titles and relevant medical license numbers.
Section E requires accurate patient population data from the past 12 months. Fill in tables detailing VFC and TVFC vaccine recipients by age group.
Finally, review Section F for program agreement statements. Ensure that the new signing clinician reads and signs at the bottom of this section.
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Refrigerated vaccines should be transported at 2C to 8C (36F to 46F). Frozen vaccines should be transported at -15C to -50C (+5F to - 58F). CDC recommends the use of portable refrigerators and freezers for vaccine transport.
Can vaccine transfer between TVFC ASN providers be allowed when necessary to avoid?
Once a provider has ordered TVFC/ASN vaccine, vaccine transfers are only allowed when necessary to avoid vaccine loss.
When should live vaccines be avoided?
Live virus vaccines are usually contraindicated in immunocompromised people, with exceptions. For example, MMR vaccine is recommended and VAR may be considered for adults with CD4+ T-cell counts of greater than or equal to 200 cells/ mcL.
What is a vaccine transfer?
CDC policy says where practical, and if the cold chain. is maintained, transfer of short-dated vaccine can occur between Childhood Vaccine Program providers to avoid wasting vaccine. Providers must coordinate a vaccine transfer using the provider map and submit their transfer request for approval in the IIS.
Can you get different vaccines close together?
Many vaccines are recommended early in life to protect young children from dangerous infectious diseases. Different childhood vaccines can be given at the same time.
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The goal of the TVFC Program is to raise childhood immunization rates in the United States without creating a financial burden for providers or families and to ensure that no TVFC-eligible child contracts a vaccine preventable disease because of his or her parents inability to pay for the vaccine or its administration
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TVFC Program - Vaccine Transfer Authorization Form
The Vaccine Transfer Authorization Form must be kept on file for a minimum of five (5) years as required by the TVFC/ASN Program and made easily accessible.
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