Public Health Department Welcomes New Division Manager for 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Facility Information section. Enter the Facility Name, Street Address, City, County, Telephone Number, State, Zip Code, and Fax Number. If your mailing address differs from your street address, provide that information as well.
3. Next, complete the Medical Director or Authorized Designee Information. Ensure you include the names and license numbers of both the Medical Director and any Authorized Designee. This section is crucial as it holds accountability for compliance.
4. Proceed to fill in the VFA Vaccine Coordinator Information. Provide details for both the Primary and Back-up Vaccine Coordinators including their names, telephone numbers, and emails.
5. Review the Provider Agreement carefully. Confirm your understanding of each condition listed before signing at the bottom of the form. Ensure all signatures are dated appropriately.
6. Finally, check all entries for accuracy before submitting your completed form back to the Division of Public Health as instructed.

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