TennIIS-Provider Agreement Add

Date:  October 04, 2026  
  • Error: Practice Name is required.
  • Error: Signatory Title is required.
  • Error: Agreement Signatory is required.
  • Error: Vaccine Delivery Street Address is required.
  • Error: Vaccine Delivery City is required.
  • Error: Vaccine Delivery State is required.
  • Error: Vaccine Delivery County is required.
  • Error: Vaccine Delivery Zip Code is required.
  • Error: Mailing Street Address is required.
  • Error: Mailing City is required.
  • Error: Mailing State is required.
  • Error: Mailing County is required.
  • Error: Mailing Zip Code is required.
  • Error: Facility Street Address is required.
  • Error: Facility City is required.
  • Error: Facility State is required.
  • Error: Facility County is required.
  • Error: Facility Zip Code is required.
  • Error: At least 2 shipping days must be selected.
  • You must complete all required fields to proceed. If you have questions regarding any of this information, please contact the Tennessee Department of Health Immunization Program at phone number (800)342-1813.

 Provider Agreement Add/Edit

Approver Comments:
Status: PENDING PROVIDER SUBMISSION
VFC PIN:
Organization Name:
Organization NPI ID:
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
A "Specialty Provider" is defined as a provider that only serves
(e.g. We are an STD clinic)
or
(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:
 Document days and times that you are able to receive vaccines:
Monday:  
Tuesday:
Wednesday:
Thursday:
Friday:
 
Provider Type:
Provider Type Other:
Facility Comments:
Is this provider a specialty provider? Yes
No
Is this provider site part of a hospital/healthcare system: Yes No N/A or don't know
Facility Type:
Is this facility a mobile facility, or does this facility have mobile units: Yes No