Common Contracts
1 similar Vaccine Provider Agreement contracts
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTVaccine Provider Agreement • January 4th, 2018
FACILITY 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 (i.e., Medical Director or Equivalent) 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: Title: Specialty: Email: License #: Medicaid or NPI #: Employer Identification #(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 a
