Common Contracts
2 similar Vermont Child Vaccine Program Provider Agreement contracts
2019/2021 VERMONT CHILD VACCINE PROGRAM PROVIDER AGREEMENTVermont Child Vaccine Program Provider Agreement • May 18th, 2020
FACILITY INFORMATION Facility Name: VFC Pin#: Facility Address: City: County: State: Zip: Telephone: Fax: Shipping Address (if different than facility address): City: County: State: Zip: MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official VFC registered health care provider signing the agreement must be a practitioner authorized to administer pediatric vaccines under state law who will also be held accountable for compliance by the entire organization and its VFC providers with the responsible conditions outlined in the provider enrollment agreement. Theindividual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): Provide Information for second individual as needed: Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.:(optional): VFC VACCINE COORDINATOR Primary Vaccine Coordinator Name: Telephone: Email: Completed annual trai
2019/2021 VERMONT CHILD VACCINE PROGRAM PROVIDER AGREEMENTVermont Child Vaccine Program Provider Agreement • January 9th, 2020
FACILITY INFORMATION Facility Name: VFC Pin#: Facility Address: City: County: State: Zip: Telephone: Fax: Shipping Address (if different than facility address): City: County: State: Zip: MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official VFC registered health care provider signing the agreement must be a practitioner authorized to administer pediatric vaccines under state law who will also be held accountable for compliance by the entire organization and its VFC providers with the responsible conditions outlined in the provider enrollment agreement. Theindividual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): Provide Information for second individual as needed: Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.:(optional): VFC VACCINE COORDINATOR Primary Vaccine Coordinator Name: Telephone: Email: Completed annual trai
