VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram 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
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • November 8th, 2022
FACILITY INFORMATION Facility Name: BLUFF CITY MEDICAL CENTER VFC Pin#: 821518 Facility Address: 229 HIGHWAY 19 E City: BLUFF CITY County: SULLIVAN State: TN Zip: 37618 Telephone: (423)538-5116 Fax: (423)538-8679 Shipping Address (if different than facility address): 229 HIGHWAY 19 E City: BLUFF CITY County: SULLIVAN State: TN Zip: 37618 MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official VFC-registered health care provider signing the agreement must be a practitioner 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 providerenrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: NEWMAN, HEATHER Title: DO Specialty:FAMILY_MEDICINE License No:0000057011 Medicaid or NPI No:Q036999/1699014068 Employer Identification Number: Email: VFC VACCINE COORDINATOR Primary Vaccine Coordinato
VIRGINIA VACCINES FOR ADULTS PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • September 7th, 2023
FACILITY INFORMATION Facility Name: Pin#:(leave blank if not known) Facility Address: City: County: State: Virginia Zip: Telephone: Fax: Shipping Address (if different than facility address): City: County: State: Virginia Zip: MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official VVFA registered health care provider signing the agreement must be a practitioner authorized to administer vaccines under state law who will also be heldaccountable for compliance by the entire organization and its VVFA providers with the responsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement (page 4). Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): Provide Information for second individual as needed: A second “Medical Director or Equivalent (pg.1)” and second signature line (pg.4) are intended for pharmacists thatrequire a physician to co‐sign the Provider Agreement.
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • May 26th, 2021
INSTRUCTIONS The Medical Director or equivalent must review, date and sign the Provider Agreement. The completed Provider Agreement can be emailed to ChicagoVFC@cityofchicago.org or faxed to the Vaccine Management Unit at312-746-6220 by July 31st, 2021. Providers who do not submit by August 15th will be unable to order VFCvaccine until the Provider Agreement is submitted. FACILITY INFORMATION Facility Name: VFC Pin#: 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 of which I am the medical director or equivalent: 1. I will annually submit a provider profile representing populations served by my practice/facility. I willsubmit more frequently if 1) the number of children served changes or 2) the status of the facility changes during the calendar year. 2. I will screen patients and document eligibility status at each immuni
Exhibit 10.5 PROGRAM PROVIDER AGREEMENT This agreement ("Agreement") is effective as of August 1, 2002 ("Effective Date"), between Citibank (South Dakota), N.A., Citibank USA N.A., and Citicorp Credit Services, Inc. (the entities above individually...Program Provider Agreement • December 16th, 2003 • Intersections Inc • South Dakota
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • March 10th, 2014
FACILITY INFORMATION Facility Name: VFC 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 VFC registered health care provider signing the agreement must be a practitioner 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. Theindividual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): VFC VACCINE COORDINATOR Primary Vaccine Coordinator Name: Telephone: Email: Completed annual training:O Yes O No Type of training received: Back‐Up Vaccine Coordinator Name: Telephone: Email: Completed annual training:O Yes O No Type of training received:
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • October 28th, 2023
FACILITY INFORMATION Facility Name: VFC 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 VFC-registered health care provider signing the agreement must be a practitioner 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. *Note: For the purposes of the VFC program, the term ‘vaccine’ is defined as any FDA-authorized or licensed, ACIP-recommended product for which ACIP approves a VFC resolution for inclusion in the VFC program. Last Name, First, MI: Title: Specialty: License No: Medicaid or NPI No: Employer Identification Number: Email: VFC VACCINE COORDINATOR Primary Vaccine Coordinator Na
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • November 10th, 2015
FACILITY INFORMATION Facility Name: VFC 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 VFC registered health care provider signing the agreement must be a practitioner authorized to administer pediatric vaccines under sta te law who will also be held accountable for compliance by the entireorganization and its VFC providers with the responsible conditions outlined in the provider enrollment agreement. Theindividual 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): VFC VACCINE COORDINATOR Primary Vaccine Coordinator Name: Telephone: Email: Completed annual trai
Veterans Choice Program Provider AgreementProgram Provider Agreement • September 4th, 2021
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VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • October 28th, 2021
FACILITY INFORMATION Facility Name: VFC 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 VFC-registered health care provider signing the agreement must be a practitioner 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 providerenrollment agreement. 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: 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 annual training: Yes No Type of training received:
Hospital Program Provider AgreementProgram Provider Agreement • January 11th, 2018
THIS AGREEMENT, made this day of 20 , by and between THE PEOPLE OF THE STATE OF NEW YORK, acting by and through the Commissioner of Health(hereinafter referred to as the STATE) Party of the First Part, and the
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • January 24th, 2022
FACILITY INFORMATION Facility Name: BLUFF CITY MEDICAL CENTER VFC Pin#: 821518 Facility Address: 229 HIGHWAY 19 E City: BLUFF CITY County: SULLIVAN State: TN Zip: 37618 Telephone: (423)538-5116 Fax: (423)538-8679 Shipping Address (if different than facility address): 229 HIGHWAY 19 E City: BLUFF CITY County: SULLIVAN State: TN Zip: 37618 MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official VFC-registered health care provider signing the agreement must be a practitioner 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 providerenrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: NEWMAN, HEATHER Title: DO Specialty:FAMILY_MEDICINE License No:0000057011 Medicaid or NPI No:Q036999/1699014068 Employer Identification Number: Email: VFC VACCINE COORDINATOR Primary Vaccine Coordinato
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • June 24th, 2014
FACILITY INFORMATION Facility Name: VFC 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 VFC registered health care provider signing the agreement must be a practitioner 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. Theindividual 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): VFC VACCINE COORDINATOR Primary Vaccine Coordinator Name: Telephone: Email: Completed annual trai
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • November 6th, 2014
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 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. Theindividual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(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 annual training: Yes No Type of traini
VACCINES FOR CHILDREN (VFC) PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • March 9th, 2022
FACILITY INFORMATION Facility Name: MOHAVE CHD-BULLHEAD CITY VFC Pin#: 0009B Facility Address: 1222 HANCOCK RD City: BULLHEAD CITY County: MOHAVE State: AZ Zip: 86442 Telephone: (928)753-0714 Fax: (928)753-0775 MEDICAL DIRECTOR OR EQUIVALENT Last Name, First, MI: NGUYEN, DAT, Title:MD Specialty: Provide Information for second individual as needed: Last Name, First, MI: Title: Specialty: VFC VACCINE COORDINATOR Primary Vaccine Coordinator Name: LEWIS, CHERINE Back-Up Vaccine Coordinator Name: GRIFFITH, KATHRYN
