Common Contracts
2 similar null contracts
STATE OF NEVADAMarch 5th, 2018
FACILITY INFORMATION Facility Name: VFC Pin: (Leave blank if new) Shipping Address: City: County: State: Zip: Telephone: Fax: Mailing Address (if different than shipping address): City: County: State: Zip: MEDICAL DIRECTOR OR EQUIVALENT (LIST ADDITIONAL PROVIDERS ON PAGE 2) Instructions: The registered health care provider signing the agreement must be a practitioner authorized to prescribe 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. The individual listed here mustsign the provider agreement. Last Name, First, MI: Title: Specialty: Email: License No.: Medicaid or NPI No.: Employer Identification No.(optional): 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 train
March 2018 – March 2019 Agreement to ParticipateJune 23rd, 2017
FACILITY INFORMATION Facility Name: VFC Pin: (Leave blank if new) Shipping Address: City: County: State: Zip: Telephone: Fax: Mailing Address (if different than shipping address): City: County: State: Zip: MEDICAL DIRECTOR OR EQUIVALENT (LIST ADDITIONAL PROVIDERS ON PAGE 2) Instructions: The registered health care provider signing the agreement must be a practitioner authorized to prescribe 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. The individual listed here mustsign the provider agreement. Last Name, First, MI: Title: Specialty: Email: License No.: Medicaid or NPI No.: Employer Identification No.(optional): 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 train
