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Practice Registration DelVAX Facility Code Request Form

Practice Registration DelVAX Facility Code Request Form 2025

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The document is a registration form for facilities that administer immunizations and wish to report these via HL7 messaging to the Delaware Immunization Program. It includes sections for practice registration, facility information, and details about immunization providers. The form requires contact information and participation in the Vaccines for Children Program, with instructions to fax the completed form to the Immunization Program.

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How to use or fill out Practice Registration DelVAX Facility Code Request Form

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Click ‘Get Form’ to open it in the editor.
Begin by selecting whether you are registering your practice for immunization reporting or requesting a facility code for electronic reporting. Check the appropriate box.
Fill in your organization name and indicate if you participate in the Vaccines for Children Program (VFC) by checking 'Yes' or 'No' and providing your VFC PIN if applicable.
Complete the Group/Practice Information section with your practice name, address, phone number, email, fax, city, state, and ZIP code.
Provide contact information for both the general contact and IT contact within your organization.
If your office information differs from the group information, fill out the Office Information section accordingly.
List all immunization ordering providers along with their NPI numbers. Use additional pages if necessary.
Similarly, list all immunization administering providers with their NPI numbers as required.
Once completed, fax the form to the Immunization Program at 302-744-5363.

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How to get my vaccination records from Delaware?

Contact the Immunization Program at 800-282-8672 or DelVAX@delaware.gov. Responses to emails and calls received after normal business hours and on weekends may take up to 48 hours to occur.

What vaccines are required for school in Delaware?

Delaware required immunizations: 5 or more doses of DTaP or DTP Td vaccine (unless 4th dose was given after the 4th birthday) 4 doses of IPV or OPV (unless 3rd dose was given after the 4th birthday) 3 doses of Hepatitis B vaccine. 2 doses of Measles, Mumps and Rubella vaccine.