VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • January 10th, 2023
Contract Type FiledJanuary 10th, 2023INSTRUCTIONS The Medical Director or equivalent must review, date and sign the Provider Agreement. The completed Provider Agreement can be emailed to ChicagoVFC@cityofchicago.org or faxed to the Vaccine Management Unit at312-746-6220 by April 15th, 2023. Providers who do not submit by April 15th will be unable to order VFCvaccine until the Provider Agreement is submitted. FACILITY INFORMATION Facility Name: VFC Pin#: PROVIDER AGREEMENT To receive publicly funded vaccines at no cost, I agree to the following conditions, on behalf of myself and all the practitioners, nurses, and others associated with the health care facility of which I am the medical director orequivalent: 1. I will annually submit a provider profile representing populations served by my practice/facility. I will submit more frequently if 1) the number of children served changes or 2) the status of the facilitychanges during the calendar year. 2. I will screen patients and document eligibility status at each immuniz