Date:  August 17, 2022  
 Provider Agreement Add/Edit
Approver Comments:
Status: PENDING PROVIDER SUBMISSION
VFC PIN:
Organization Name:
Facility Name:
Agreement Signatory:
Agreement Signatory Title:
Is Information Sharing Agreement current? Yes No
Last Renewed:
 Facility Address:
Street Address:
Street Address2:
City:
State:
County:
Zip Code:
 Vaccine Delivery Address:
Check if vaccine delivery address is the same as facility address:
Street Address:
Street Address2:
City:
State:
County:
Zip Code:
 Mailing Address:
Check if mailing address is the same as facility address:
Street Address:
Street Address2:
City:
State:
County:
Zip Code:
 Contact Details:
Type1:
Contact First Name1, Middle Initial 1, and Last Name 1:
Phone Number1:
Phone Number Extension1:
Fax Number1:
Email Address1:
Completed Annual Training1:
Yes No
Type Of Training Received1:
 
Type2:
Contact First Name2, Middle Initial 2, and Last Name 2:
Phone Number2:
Phone Number Extension2:
Fax Number2:
Email Address2:
Completed Annual Training2:
Yes No
Type Of Training Received2:
 
Type3:
Contact First Name3, Middle Initial 3, and Last Name 3:
Phone Number3:
Phone Number Extension3:
Fax Number3:
Email Address3:
Completed Annual Training3:
Yes No
Type Of Training Received3:
 
Type4:
Contact First Name4, Middle Initial 4, and Last Name 4:
Phone Number4:
Phone Number Extension4:
Fax Number4:
Email Address4:
Completed Annual Training4:
Yes No
Type Of Training Received4:
 
Type5:
Contact First Name5, Middle Initial 5, and Last Name 5:
Phone Number5:
Phone Number Extension5:
Fax Number5:
Email Address5:
Completed Annual Training5:
Yes No
Type Of Training Received5:
 Vaccines Offered
All ACIP Recommended Vaccines
Offers Selected Vaccines (This option is only available for facilities designated as Specialty Providers by the VFC Program)
A "Specialty Provider" is defined as a provider that only serves
A defined population due to practice specialty (e.g. OB/GYN; STD Clinic; family planning). Please specify:
(e.g. We are an STD clinic)
or
A specific age group within the general population of children ages 0-18. Please specify:
(e.g. We serve children ages 0-6 years)
Local health departments and pediatricians are not considered specialty providers. The VFC Program has the authority to designate VFC providers as specialty providers. At the discretion of the VFC Program, enrolled providers such as pharmacies and mass vaccinators may offer only influenza vaccine.
Select Vaccines Offered by Specialty Provider:
DTaP Meningococcal Conjugate TD
Hepatitis A MMR Tdap
Hepatitis B Pneumococcal Conjugate Varicella
HIB Pneumococcal Polysaccharide Other:
HPV Polio
Influenza Rotavirus
 Document days and times that you are able to receive vaccines:
Monday:  
Tuesday:
Wednesday:
Thursday:
Friday:
Facility Type:
Facility Type Other:
Facility Comments: