TEXAS VACCINES FOR CHILDREN PROGRAM (TVFC): PROVIDER ENROLLMENT Initial enrollment* Reenrollment (*C 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Provider PIN Number at the top of the form. If you do not have a PIN, contact your local Health Services Region (HSR).
3. Fill in the Responsible Entity and Name of Facility, Practice, or Clinic. Ensure all names are spelled correctly for accurate processing.
4. Complete the Provider Name section with the last name, first name, middle initial, and title of the provider.
5. Provide contact information including mailing address, telephone number, and email address. Double-check for accuracy to avoid communication issues.
6. Review and agree to the terms outlined in the agreement section. Ensure that all conditions are understood before signing.
7. Sign and date the form at the bottom. Only licensed professionals can sign this document.

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