Common Contracts
1 similar Program Provider Agreement contracts
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • October 28th, 2021
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 providerenrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No: Medicaid or NPI No: Employer Identification Number: Email: VFC VACCINE COORDINATOR Primary Vaccine Coordinator Name: Telephone: Email: Completed annual training: Yes No Type of training received: Back-Up Vaccine Coordinator Name: Telephone: Email: Completed annual training: Yes No Type of training received:
