DELAWARE BRIDGE PROGRAM PROVIDER AGREEMENTDelaware Bridge Program Provider Agreement • September 13th, 2023
FACILITY INFORMATION Facility Name: Pin# (if applicable): 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 Delaware 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 Delaware 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 Advisory Committee on ImmunizationPractices (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: Delaware Bridge Program VACCINE COORDINATOR Primary Vacc
