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MAINE VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTMay 5th, 2020
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 provider enrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI:License No.: Title: Specialty: 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): VFC VACCINE COORDINATOR Primary Vaccine Coordinator Name: Telephone: Email: Completed annual trai
