2019 tvfc and asn program re enrollmentent hsr 11-2025

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The document outlines the Vaccines for Children (VFC) Program Provider Agreement, detailing the responsibilities and requirements for healthcare providers participating in the program. It includes sections on facility information, medical director details, vaccine coordinators, provider compliance conditions, eligibility criteria for VFC vaccines, record-keeping obligations, and guidelines for administering vaccines to eligible children at no cost. The agreement emphasizes accountability for adherence to immunization practices and program regulations.

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Click ‘Get Form’ to open the 2019 tvfc and asn program re enrollmentent hsr 11 in the editor.
Begin by filling out the Facility Information section. Enter your Facility Name, VFC Pin, Address, City, County, State, Telephone, Zip, and Fax. If your shipping address differs from your facility address, provide that information as well.
In the Medical Director or Equivalent section, input the Last Name, First Name, MI, Title, Specialty, License No., Medicaid or NPI No., Employer Identification No. (optional), and Email of the authorized practitioner.
Complete the Vaccine Coordinator details by entering the Primary Vaccine Coordinator's name and contact information. Indicate if they have completed annual training.
List all providers practicing at your facility in the designated section. Include their names, titles, license numbers, and NPI numbers where applicable.
Review and agree to the Provider Agreement terms outlined in the form. Ensure you understand each condition before signing.
Once all sections are filled out accurately, save your changes and submit the form directly through our platform for a seamless experience.

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