Common Contracts
1 similar null contracts
KANSAS IMMUNIZATION PROGRAM 317 PROGRAM PROVIDER AGREEMENTApril 8th, 2019
FACILITY INFORMATION Facility Name: PIN: Facility Address: City: County: State: Zip: Telephone: Fax: Shipping Address (if different than facility address): City: County: State: Zip: Vaccine Delivery Hours:Closed for lunch: : AM/PM to : Monday : AM/PM to : AM/PM Tuesday : AM/PM to : AM/PM Wednesday : AM/PM to : AM/PM Thursday : AM/PM to : AM/PM Friday : AM/PM to : AM/PM MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official registered health care provider signing the agreement must be a practitioner authorized to administer adult vaccines under Kansas state law who will also be held accountable for compliance by the entire organization and its providers with theresponsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement. Last, First, MI: Title (MD, DO, NP, PA) Specialty: License Number: NPI Number: Email: Provider Information for second individual as needed Last, First, MI: Title (MD, DO, NP, PA) Specialty: Li
