Common use of Valid License Clause in Contracts

Valid License. Capacity Agreement Why Renew? • Verify eligibility • Capture updated info and data • Annual provider training requirement * If you have not completed your Provider Agreement Renewal within 30 days of your Renewal Due Date, you will be disenrolled from the program. • Facility Information/Contact Details • Vaccines Offered • Shipping Information Page 2: Provider Page 3: Provider/Practice Profile • Practice Profile • Data Sources Page 4: Certify Frozen Vaccine Getting to your Provider Agreement Renewal: • Log into the IIS • Under “Orders/Transfers” select “Provider Agreement” • Click “Add” • Complete your 2024 Provider Agreement Renewal This page contains 3 sections: o Facility Information/Contact Details ▪ Facility Name and PIN ▪ Addresses – Facility address, Vaccine delivery address, Mailing address ▪ Contact Details – must include name, phone number, and email address ▪ Signatory ▪ Primary Coordinator ▪ Backup Coordinator ▪ Billing Coordinator ▪ Two additional optional contacts o Vaccines Offered o Shipping Information • Verify facility name and address • The following changes require a signed copy of your agreement to be submitted to DOH. o Update to your facility name o Change to your signatory o Update to any address • If making any of the changes listed above, send a signed copy of your agreement to DOH at XXXxxxxxxxxXxxxxxxx@xxx.xx.xxx or by fax to (000)000-0000 • If none of the above changes have occurred, simply update your agreement online and submit the provider agreement electronically. Signatory • First contact • Phone number & email • Authority at the facility • Active provider with a valid license Primary/Backup Coordinators • Second and third contact • Phone number & email addresses • Annual training o Only online training (You Call The Shots) will be accepted o xxxxx://xxx.xxx.xxx/vaccines/ed/youcalltheshots. html o Complete “Vaccines for Children (VFC)” and “Vaccine Storage and Handling” modules Billing Coordinator • Fourth contact • Can be an individual or a group • Must include email address & phone number Verify vaccines offered • All ACIP recommended vs. Specialty Provider • If a specialty provider: o Defined population vs. age group o Choose specialty vaccine(s) All ACIP Recommended: Specialty Provider Information: • Verify/change days and times • Do NOT change facility type! • Must be available four consecutive hours, twice a week, Monday through Friday Do NOT change facility type Continue to • Medical License Number required • NPI Number required • Signatory will pre- populate based on contact information section Verify provider info Signatory will prepopulate • If a pharmacist is an authorized provider, please submit a copy of the collaborative agreement to XXXxxxxxxxxXxxxxxxx@xxx.xx.xxx This page contains 2 sections: o Practice Profile o Data Sources Practice Profile o Number of VFC eligible vs. non-VFC eligible children o State vs. federal funding • Number of children receiving vaccine: January 1, 2023 – December 31, 2023 • Based on patient records • Only count a child once • Log into the IIS

Valid License. Capacity Agreement Why Renew? • Verify eligibility • Capture updated info and data • Annual provider training requirement Renewal Start Date March 1, 2020 March 1, 2020 April 1, 2020 Renewal Due Date * March 31, 2020 April 30, 2020 April 30, 2020 Xxxxx Xxxxx Xxxx Xxxxxx-Xxxxxxxx San Xxxx Asotin NE Tri Snohomish Chelan-Xxxxxxx Xxxxxx Columbia Pacific Clallam Skamania Cowlitz Xxxxxx Xxxxx Whatcom Garfield Spokane Xxxxx Xxxxxxx Counties Grays Harbor Xxxxxxxx Island Kittitas Wahkiakum Jefferson Klickitat Walla Walla Kitsap Xxxxx Yakima Okanogan Lincoln * If you have not completed your Provider Agreement Renewal within 30 days of your Renewal Due Date, you will be disenrolled from the program. • Facility Information/Contact Details • Vaccines Offered • Shipping Information Page 2: Provider Page 3: Provider/Practice Profile • Practice Profile • Data Sources Page 4: Certify Frozen Vaccine Getting to your Provider Agreement Renewal: • Log into the IIS • Under “Orders/Transfers” select “Provider Agreement” • Click “Add” • Complete your 2024 2020 Provider Agreement Renewal This page contains 3 sections: o • Facility Information/Contact Details ▪  Facility Name and PIN ▪  Addresses – Facility address, Vaccine delivery address, Mailing address ▪  Contact Details – must include name, phone number, and email address ▪  Signatory ▪  Primary Coordinator ▪ New this year!  Backup Coordinator ▪  Billing Coordinator ▪  Two additional optional contacts o • Vaccines Offered o • Shipping Information • Verify facility name and address • The following changes require a signed copy of your agreement to be submitted to DOH. o • Update to your facility name o • Change to your signatory o • Update to any address • If making any of the changes listed above, send a signed copy of your agreement to DOH at XXXxxxxxxxxXxxxxxxx@xxx.xx.xxx or by fax to (000)000-0000 • If none of the above changes have occurred, simply update your agreement online and submit the provider agreement electronically. Signatory • First contact • Phone number & email • Email • Authority at the facility • Active provider with a valid license Primary/Backup Coordinators • Second and third contact • Phone number & email addresses • Email • Annual training o • Only online training (You Call The Shots) will be accepted o xxxxx://xxx.xxx.xxx/vaccines/ed/youcalltheshots. html o • xxxxx://xxx.xxx.xxx/vaccines/ed/youcalltheshots.html • Complete “Vaccines for Children (VFC)” and “Vaccine Storage and Handling” modules Billing Coordinator • Fourth New in 2020: Contact Type 4 This year it is required that you include a billing contact • Can be an individual or a group • Must at your facility. Please include name, phone number, and email address & phone number Verify vaccines offered • All ACIP recommended vs. Specialty Provider • If a specialty provider: o • Defined population vs. age group o • Choose specialty vaccine(s) All ACIP Recommended: Specialty Provider Information: WA State DOH | 13 • Verify/change days and times • Do NOT change facility type! • Must be available four consecutive hours, twice a week, Monday through Friday Do NOT change facility type Continue to • Medical License Number Page 2 What is required • NPI Number this year in your Contact Details that was not required • Signatory will pre- populate based on contact information section Verify provider info Signatory will prepopulate • If a pharmacist is an authorized provider, please submit a copy of the collaborative agreement to XXXxxxxxxxxXxxxxxxx@xxx.xx.xxx This page contains 2 sections: o Practice Profile o Data Sources Practice Profile o Number of VFC eligible vs. non-VFC eligible children o State vs. federal funding • Number of children receiving vaccine: January 1, 2023 – December 31, 2023 • Based on patient records • Only count a child once • Log into the IISlast year?

Valid License. Capacity Agreement Why Renew? • Verify eligibility • Capture updated info and data • Annual provider training requirement Renewal Start Date March 1, 2020 March 1, 2020 April 1, 2020 Renewal Due Date * March 31, 2020 April 30, 2020 April 30, 2020 Xxxxx Xxxxx Xxxx Xxxxxx-Xxxxxxxx San Xxxx Asotin NE Tri Snohomish Chelan-Xxxxxxx Xxxxxx Columbia Pacific Clallam Skamania Cowlitz Xxxxxx Xxxxx Whatcom Garfield Spokane Xxxxx Xxxxxxx Counties Grays Harbor Xxxxxxxx Island Kittitas Wahkiakum Jefferson Klickitat Walla Walla Kitsap Xxxxx Yakima Okanogan Lincoln * If you have not completed your Provider Agreement Renewal within 30 days of your Renewal Due Date, you will be disenrolled from the program. • Facility Information/Contact Details • Vaccines Offered • Shipping Information Page 2: Provider Page 3: Provider/Practice Profile • Practice Profile • Data Sources Page 4: Certify Frozen Vaccine Getting to your Provider Agreement Renewal: • Log into the IIS • Under “Orders/Transfers” select “Provider Agreement” • Click “Add” • Complete your 2024 2020 Provider Agreement Renewal This page contains 3 sections: o • Facility Information/Contact Details ▪ Facility Name and PIN ▪ Addresses – Facility address, Vaccine delivery address, Mailing address ▪ Contact Details – must include name, phone number, and email address ▪ Signatory ▪ Primary Coordinator New this year! ▪ Backup Coordinator ▪ Billing Coordinator ▪ Two additional optional contacts o • Vaccines Offered o • Shipping Information • Verify facility name and address • The following changes require a signed copy of your agreement to be submitted to DOH. o • Update to your facility name o • Change to your signatory o • Update to any address • If making any of the changes listed above, send a signed copy of your agreement to DOH at XXXxxxxxxxxXxxxxxxx@xxx.xx.xxx or by fax to (000)000-0000 • If none of the above changes have occurred, simply update your agreement online and submit the provider agreement electronically. Signatory • First contact • Phone number & email • Email • Authority at the facility • Active provider with a valid license Primary/Backup Coordinators • Second and third contact • Phone number & email addresses • Email • Annual training o • Only online training (You Call The Shots) will be accepted o xxxxx://xxx.xxx.xxx/vaccines/ed/youcalltheshots. html o • xxxxx://xxx.xxx.xxx/vaccines/ed/youcalltheshots.html • Complete “Vaccines for Children (VFC)” and “Vaccine Storage and Handling” modules Billing Coordinator • Fourth New in 2020: Contact Type 4 This year it is required that you include a billing contact • Can be an individual or a group • Must at your facility. Please include name, phone number, and email address & phone number Verify vaccines offered • All ACIP recommended vs. Specialty Provider • If a specialty provider: o • Defined population vs. age group o • Choose specialty vaccine(s) All ACIP Recommended: Specialty Provider Information: • Verify/change days and times • Do NOT change facility type! • Must be available four consecutive hours, twice a week, Monday through Friday Do NOT change facility type Continue to • Medical License Number Page 2 What is required • NPI Number this year in your Contact Details that was not required • Signatory will pre- populate based on contact information section Verify provider info Signatory will prepopulate • If a pharmacist is an authorized provider, please submit a copy of the collaborative agreement to XXXxxxxxxxxXxxxxxxx@xxx.xx.xxx This page contains 2 sections: o Practice Profile o Data Sources Practice Profile o Number of VFC eligible vs. non-VFC eligible children o State vs. federal funding • Number of children receiving vaccine: January 1, 2023 – December 31, 2023 • Based on patient records • Only count a child once • Log into the IISlast year?

Valid License. Capacity Agreement Why Renew? • Verify eligibility • Capture updated info and data • Annual provider training requirement * If you have not completed your Provider Agreement Renewal within 30 days of your Renewal Due Date, you will be disenrolled from the program. Page 1: Facility Information • Facility Information/Contact Details • Vaccines Offered • Shipping Information Page 2: Provider Page 3: Provider/Practice Profile • Practice Profile • Data Sources Page 4: Certify Frozen Vaccine Getting to your Provider Agreement Renewal: • Log into the IIS • Under “Orders/Transfers” select “Provider Agreement” • Click “Add” • Complete your 2024 2023 Provider Agreement Renewal This page contains 3 sections: o Facility Information/Contact Details ▪ Facility Name and PIN ▪ Addresses – Facility address, Vaccine delivery address, Mailing address ▪ Contact Details – must include name, phone number, and email address ▪ Signatory ▪ Primary Coordinator ▪ Backup Coordinator ▪ Billing Coordinator ▪ Two additional optional contacts o Vaccines Offered o Shipping Information • Verify facility name and address • The following changes require a signed copy of your agreement to be submitted to DOH. o Update to your facility name o Change to your signatory o Update to any address • If making any of the changes listed above, send a signed copy of your agreement to DOH at XXXxxxxxxxxXxxxxxxx@xxx.xx.xxx or by fax to (000)000-0000 • If none of the above changes have occurred, simply update your agreement online and submit the provider agreement electronically. Signatory • First contact • Phone number & email • Authority at the facility • Active provider with a valid license Primary/Backup Coordinators • Second and third contact • Phone number & email addresses • Annual training o Only online training (You Call The Shots) will be accepted o xxxxx://xxx.xxx.xxx/vaccines/ed/youcalltheshots. html o Complete “Vaccines for Children (VFC)” and “Vaccine Storage and Handling” modules Billing Coordinator • Fourth contact • Can be an individual or a group • Must include email address & phone number Verify vaccines offered • All ACIP recommended vs. Specialty Provider • If a specialty provider: o Defined population vs. age group o Choose specialty vaccine(s) All ACIP Recommended: Specialty Provider Information: • Verify/change days and times • Do NOT change facility type! • Must be available four consecutive hours, twice a week, Monday through Friday Do NOT change facility type Continue to Verify provider info • Medical License Number required • NPI Number required • Signatory will pre- populate based on contact information section Verify provider info Signatory will prepopulate • If a pharmacist is an authorized provider, please submit a copy of the collaborative agreement to XXXxxxxxxxxXxxxxxxx@xxx.xx.xxx This page contains 2 sections: o Practice Profile o Data Sources Practice Profile o Number of VFC eligible vs. non-VFC eligible children o State vs. federal funding • Number of children receiving vaccine: January 1, 2023 2022 – December 31, 2023 2022 • Based on patient records • Only count a child once • Log into the IIS