Health alaska dphEpi2020 Provider Agreement to Receive State-Supplied Vaccine 2026

1. Click ‘Get Form’ to open the health alaska dphEpi2020 Provider Agreement in our editor.
2. Begin by entering your Facility Name and Phone Number with Area Code in the designated fields. This information is crucial for identification and communication.
3. Fill in the VFC PIN / USIIS ID, ensuring accuracy as this links your facility to the vaccine program.
4. For each vaccine type listed, select from the dropdown options and provide details such as Manufacturer, Lot Number, NDC Number, Expiration Date, and Number of Doses. Each vaccine should have its own row for clarity.
5. After entering all required information for each vaccine type, calculate the Grand Total by summing up the doses for each category and inputting that number in the Grand Total column.
6. Once completed, retain a copy for your records. Submit your report along with your vaccine order via email to vacteam@utah.gov.

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