Common Contracts
1 similar Program Provider Agreement contracts
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • May 26th, 2021
INSTRUCTIONS 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 July 31st, 2021. Providers who do not submit by August 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 or equivalent: 1. I will annually submit a provider profile representing populations served by my practice/facility. I willsubmit more frequently if 1) the number of children served changes or 2) the status of the facility changes during the calendar year. 2. I will screen patients and document eligibility status at each immuni
