Common Contracts
1 similar Program Provider Agreement contracts
VIRGINIA VACCINES FOR ADULTS PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • September 7th, 2023
FACILITY INFORMATION Facility Name: Pin#:(leave blank if not known) Facility Address: City: County: State: Virginia Zip: Telephone: Fax: Shipping Address (if different than facility address): City: County: State: Virginia Zip: MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official VVFA registered health care provider signing the agreement must be a practitioner authorized to administer vaccines under state law who will also be heldaccountable for compliance by the entire organization and its VVFA providers with the responsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement (page 4). Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): Provide Information for second individual as needed: A second “Medical Director or Equivalent (pg.1)” and second signature line (pg.4) are intended for pharmacists thatrequire a physician to co‐sign the Provider Agreement.
