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VIRGINIA VACCINES FOR ADULTS BRIDGE (VVAB) PROGRAM PROVIDER AGREEMENTSeptember 7th, 2023
FACILITY INFORMATION Facility Name: Pin# (if applicable): Facility Address: City: County: State: Virginia Zip: Telephone: Fax: Shipping Address (if different than facility address): City: County: State: Virginia Zip: MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official Virginia Vaccines for Adults Bridge program registered health care provider signing the agreement must be a practitioner authorized to administer vaccines under state law who will also be held accountable for compliance by the entire organization and its Virginia Vaccines for Adults Bridge program providers with the responsible conditions outlined in the provider enrollment agreement. For the purposes of this agreement, a vaccine is defined as any vaccine or vaccine-like product recommended by the AdvisoryCommittee on Immunization Practices (ACIP). The individual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No: Medicaid or NPI No: Employer Identification Number: Email
