Common Contracts

1 similar VFC Program Participation Agreement contracts

STATE OF NEVADA
VFC Program Participation Agreement • March 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

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