Common Contracts
2 similar Provider Agreement contracts
ContractProvider Agreement • December 15th, 2016
PROVIDER AGREEMENT To receive publicly funded vaccines at no cost, I agree to the following conditions, on behalf of myself and all the practitioners, nurses, and others associated with the health care facility ofwhich I am the medical director or equivalent: 1. I will annually submit a provider profile representing populations served by my practice/facility. I will submit more frequently if 1) the number of children served changes or 2) the status of thefacility changes during the calendar year. 2. I will screen patients and document eligibility status at each immunization encounter for VFC eligibility (i.e., federally or state vaccine-eligible) and administer VFC-purchased vaccine by such category only to children who are 18 years of age or younger who meet one or more of the following categories: A. Federally Vaccine-eligible Children (VFC eligible)1. Are an American Indian or Alaska Native;2. Are enrolled in Medicaid;3. Have no health insurance;4. Are underinsured: A child who ha
ContractProvider Agreement • March 24th, 2016
PROVIDER AGREEMENT To receive publicly funded vaccines at no cost, I agree to the following conditions, on behalf of myself and all the practitioners, nurses, and others associated with the health care facility ofwhich I am the medical director or equivalent: 1. I will annually submit a provider profile representing populations served by my practice/facility. I will submit more frequently if 1) the number of children served changes or 2) the status of thefacility changes during the calendar year. 2. I will screen patients and document eligibility status at each immunization encounter for VFC eligibility (i.e., federally or state vaccine-eligible) and administer VFC-purchased vaccine by such category only to children who are 18 years of age or younger who meet one or more of the following categories: A. Federally Vaccine-eligible Children (VFC eligible)1. Are an American Indian or Alaska Native;2. Are enrolled in Medicaid;3. Have no health insurance;4. Are underinsured: A child who ha
