Please complete Sections A and B of this form as follows:CDC Covid-19 Vaccination Program Provider Agreement • September 29th, 2020
The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location covered under the Organization listed in Section A.
Provider AgreementCDC Covid-19 Vaccination Program Provider Agreement • November 15th, 2020
The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location (Location) covered under the Organization listed in Section A.
Agreement requirementsCDC Covid-19 Vaccination Program Provider Agreement • October 9th, 2020
Please complete Sections A and B of this form as follows:CDC Covid-19 Vaccination Program Provider Agreement • March 22nd, 2021
This CDC COVID-19 Vaccination Program Provider Agreement for Network Dialysis Centers (Agreement) specifies the conditions for receiving COVID-19 Vaccine from the United States government.
Enrolling for COVID-19 Vaccine – Agreement DescriptionsCDC Covid-19 Vaccination Program Provider Agreement • October 30th, 2020
Every organization will need a signed Section A agreement; one of these signed agreements may cover many locations. Section B will be completed for each location associated with the organization in Section A that will administer vaccine.
Please complete Sections A and B of this form as follows:CDC Covid-19 Vaccination Program Provider Agreement • October 23rd, 2020
The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination Location covered under the Organization listed in Section A.
Steps to Complete the Program Provider Enrollment ProcessCDC Covid-19 Vaccination Program Provider Agreement • October 23rd, 2020
Every healthcare organization/vaccination provider that would like to order and receive COVID-19 vaccine will need to complete the CDC COVID-19 Vaccination Program Provider Agreement. The forms can be found on the Alaska COVID-19 Vaccine Information for Healthcare Workers website. This is a separate agreement from the Alaska Immunization Program (VFC and AVAP). Current VFC or AVAP providers need to complete and submit the CDC COVID-19 Vaccination Program Provider Agreement to provide COVID-19 vaccine in Alaska.
Steps to Complete the Program Provider Enrollment ProcessCDC Covid-19 Vaccination Program Provider Agreement • January 28th, 2022
Step 1: Complete the CDC COVID-19 Vaccination Program Provider Agreement. Every healthcare organization/vaccination provider that would like to order and receive COVID- 19 vaccine will need to complete the CDC COVID-19 Vaccination Program Provider Agreement. The form can be found on the Alaska COVID-19 Vaccine Information for Healthcare Workers website. This is a separate agreement from the Alaska Immunization Program (VFC and AVAP). Current VFC or AVAP providers need to complete and submit the CDC COVID-19 Vaccination Program Provider Agreement to provide COVID-19 vaccine in Alaska.
Please complete Sections A and B of this form as follows:CDC Covid-19 Vaccination Program Provider Agreement • September 29th, 2020
The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location (Location) covered under the Organization listed in Section A.
Agreement and ProfileCDC Covid-19 Vaccination Program Provider Agreement • December 9th, 2020
List of licensed facility providers who will prescribe the vaccine Include provider first and last name, state license type, license number
Please complete Sections A and B of this form as follows:CDC Covid-19 Vaccination Program Provider Agreement • October 30th, 2020
in the COVID-19 vaccination effort. Eligible Pharmacy’s participation is a vital service that will protect individuals against SARS-CoV-2, the virus that causes COVID-19. The United States government has acquired the COVID-19 vaccine (COVID-19 Vaccine) and is making these publicly funded vaccines available to certain immunization providers to administer. The United States will also provide publicly funded adjuvant, syringes, needles, or other constituent products and ancillary supplies as set forth in the COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations.1
Provider AgreementCDC Covid-19 Vaccination Program Provider Agreement • December 3rd, 2020
The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination Location covered under the Organization listed in Section A.
AGREEMENT REQUIREMENTS I understand this is an agreement between Organization and CDC. This program is a part of collaboration under the relevant state, local, or territorial immunization’s cooperative agreement with CDC.To receive one or more of the...CDC Covid-19 Vaccination Program Provider Agreement • November 16th, 2020
This agreement expressly incorporates all recommendations, requirements, and other guidance that this agreement specifically identifies through footnoted weblinks. Organization must monitor such identified guidance for updates. Organization must comply with such updates.
Massachusetts COVID-19 Vaccine ProgramCDC Covid-19 Vaccination Program Provider Agreement • November 12th, 2020
The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COB+VID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary) – collectively, Responsible Officers – must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination Location covered under the Organization listed in Section A.
Steps to Complete the Program Provider Enrollment ProcessCDC Covid-19 Vaccination Program Provider Agreement • October 23rd, 2020
This is a separate agreement from the Alaska Immunization Program (VFC and AVAP). Current VFC or AVAP providers need to complete and submit the CDC COVID-19 Vaccination Program Provider Agreement to provide COVID-19 vaccine in Alaska.
Please register to provide the COVID-19 Vaccine. Complete each field and submit.CDC Covid-19 Vaccination Program Provider Agreement • May 10th, 2021
The Centers for Disease Control and Prevention (CDC) appreciates your organization's participation in the CDC COVID-19 Vaccination Program. We ask you to complete the following three steps:
DHHSCDC Covid-19 Vaccination Program Provider Agreement • November 18th, 2020
The Centers for Disease Contro and Prevention (CDC) greatly apprec ates your organization s participation in the CDC COVID19 Vacc nation Program.
