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State of tennessee immunization form 2026

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The document outlines the enrollment process and requirements for healthcare providers participating in the Tennessee Vaccines for Children (VFC) Program. It includes a provider enrollment form, guidelines for vaccine storage and handling, emergency procedures, and responsibilities of providers regarding patient eligibility, inventory management, and compliance with state and federal regulations. The document emphasizes the importance of maintaining accurate records, ensuring proper vaccine storage conditions, and adhering to protocols for administering vaccines to eligible children.

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Click ‘Get Form’ to open the State of Tennessee Immunization Form in the editor.
Begin by filling out the 'Practice Information' section. Enter your practice name, VFC PIN number, mailing address, and contact details for both primary and secondary contacts.
In the 'Vaccine Storage Units and Delivery/Receiving Hours' section, indicate the types and numbers of refrigerator and freezer storage units you have. Specify your delivery hours for vaccine shipments.
Complete the 'Patient Estimates' section by reporting the number of active patients served over a 12-month period, categorized by age groups. Ensure to include VFC eligibility details.
Review the 'Provider Agreement' carefully. Type or print your name, medical license number, date, and sign where indicated to confirm your agreement with program requirements.

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