VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • November 6th, 2014
Contract Type FiledNovember 6th, 2014FACILITY INFORMATION Facility Name: VFC Pin#: Facility (Shipping) Address: City: County: State: Zip: Telephone: Fax: Mailing Address [if different than facility address, (PO. Box)]: 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. Theindividual listed here must sign the provider agreement. 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 training: Yes No Type of training received: Back-Up Vaccine Coordinator Name: Telephone: Email: Completed annual training: Yes No Type of traini