Common Contracts
1 similar Provider Enrollment Agreement contracts
Arizona Vaccines for Adults (VFA) Program Provider Enrollment Agreement October 2015 – September 2018Provider Enrollment Agreement • August 18th, 2015
Facility Name: VFA 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 VFA registered health care provider signing the agreement must be a practitioner authorized to administer adult vaccines under state law who will also be held accountable for compliance by the entire organization and its VFA providers with the responsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): Provide Information for second individual as needed: Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.:(optional): Primary Vaccine Coordinator Name: Telephone: Email: Completed annual training: Type of training received: Yes No
