Maine Adult Vaccine Program Provider Agreement Sample Contracts
Maine Department of Health and Human Services Maine Center for Disease Control and Prevention Maine Immunization Program (MIP)Maine Adult Vaccine Program Provider Agreement • March 15th, 2022
FACILITY INFORMATION Facility Name: MIP Pin#: 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 MIP registered health care provider signing the agreement must be a practitioner authorized to administer adult vaccines under state law who will also be held accountable for compliance by the entire organization and its adult providers with the responsible conditions outlined inthe provider enrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): Provide Information for second individual as needed Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): ADULT VACCINE COORDINATOR Primary Vaccine Coordinator Name: Telephone: Email: Back-Up Vaccine Coordin