Common Contracts
1 similar Provider Agreement contracts
VACCINES FOR ADULT (VFA) PROGRAM PROVIDER AGREEMENT AND PROFILE FORMProvider Agreement • November 21st, 2018
FACILITY INFORMATION Facility Name: (complete for all applicable VFA PINs)_ PIN: _ PIN: _ PIN: _ PIN: _ Facility Address: City: County: State: Zip: Telephone: Fax: Email: Shipping Address (if different than facility address): City: County: State: Zip: Vaccine Delivery Hours:Closed for Lunch: ___:_ am/pm to _: _ M: _: am/pm to :_ am/pm Tu: ___:___am/pm to am/pm W :_ am/pm to :_ am/pm Th: :_ am/pm to :_ am/pm F: : _am/pm to am/pm MEDICAL DIRECTOR OR EQUIVALENT ( may include; MD, NP, DO, or PA) Instructions: The official Vaccines for Adults registered health care provider signing the agreement must be a practitioner authorized to administer vaccines under state law. He/she will also be held accountable for complianceof the entire organization and its providers with the 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
