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Florida Vaccines for Children (VFC) Program

Provider Initial Enrollment Form

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If you have questions or encounter problems completing this form, contact the Florida Vaccines for Children Program at 1 (800) 483-2543.

* Indicates required field.

Provider Information

*Name of physician's office, practice, or clinic:

*Date:

*Mailing address:

*County:

*City:

*Zip code:

*Contact person:

*Email address:

*Telephone number:

*Fax number:

*Check the one provider category that best describes you:

Physician	Community Health Center	Physician Assistant
Group Practice	Federally Qualified Health Center	Nurse Practitioner
HMO	Rural Health Clinic	Walk-In Clinic
Hospital	County Public Health Unit	Other (specifiy)

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Provider Profile Section

Please note: This section is very important. It provides necessary shipping information and helps determine the amount of vaccine the VFC Program will supply.

*Shipping Address (must be a street address, no P.O. boxes):

*City:

*Zip Code:

Delivery instructions (Please enter the days of the week and times, between the hours of 8 AM and 5 PM, your local time, you may receive vaccine deliveries, enter closed if you are not open on a specific day.):

Day of the Week	*Opening Time	Closed for Lunch	Open after Lunch	*Closing Time
Monday
Tuesday
Wednesday
Thursday
Friday

*In a 12-month period, estimate the number of VFC Program-eligible children, by age and eligibility, who will be immunized at this location: (For example: 3 in the “< 1 year old” category, 4 in the “1-6 years old” category, and 2 in the “7-18 years old” yields 9 total). (Note: Do not count a child in more than one category.)

VFC Eligibility	<1 Year	1-6 Years	7-18 Years	Total
Enrolled in Medicaid
Without Health Insurance
American Indian/Alaskan Native
Underinsured (has health insurance but it does not cover immunizations)
Total

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Provider List Section

List the names and medical license numbers of all healthcare providers who may administer vaccines at this location.

*Last name:	*First name:	MI:	*Title (MD, PA, etc.):

*Medical license number:	*Speciality (pediatrics, family medicine, etc.):

Last name:	First name:	MI:	Title (MD, PA, etc.):

Medical license number:	Speciality (pediatrics, family medicine, etc.):

Last name:	First name:	MI:	Title (MD, PA, etc.):

Medical license number:	Speciality (pediatrics, family medicine, etc.):

Last name:	First name:	MI:	Title (MD, PA, etc.):

Medical license number:	Speciality (pediatrics, family medicine, etc.):

Last name:	First name:	MI:	Title (MD, PA, etc.):

Medical license number:	Speciality (pediatrics, family medicine, etc.):

Last name:	First name:	MI:	Title (MD, PA, etc.):

Medical license number:	Speciality (pediatrics, family medicine, etc.):

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Submit Application
By pressing "Submit" you agree to the following terms and conditions:
In order to participate in the Vaccines for Children (VFC) Program and/or to receive other federally procured vaccine provided to me at no cost, I, on behalf of myself and all practitioners associated with this medical office, group practice, health maintenance organization, health department, community/rural clinic, or other entity of which I am the physician-in-chief or equivalent, agree to the following: I. Screen patients at all immunization encounters for eligibility and administer VFC-purchased vaccine only to children who are 18 years of age or younger, and meet one or more of the following categories: A. Federally vaccine-eligible 1. American Indian or Alaskan Native 2. Enrolled in Medicaid 3. Has no health insurance 4. Underinsured: Children who have commercial (private) health insurance but the coverage does not include vaccines, children whose insurance covers only selected vaccines (VFC-eligible for non-covered vaccines only), or children whose insurance caps vaccine coverage at a certain amount--once that coverage amount is reached, these children are categorized as underinsured. Underinsured children are eligible to receive VFC vaccine only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). II. Comply with immunization schedule, dosage, and contraindications that are established by the ACIP and included in the VFC Program, unless: A. In the provider’s medical judgment, and in accordance with accepted medical practice, the provider deems such compliance to be medically inappropriate. B. The particular requirements contradict state law, including those pertaining to religious and other exemptions. III. Maintain all records related to the VFC Program for a minimum of three years and make these records available to public health officials, including the state or Department of Health and Human Resources (DHHR), and Department of Health and Human Services (DHHS), upon request. IV. Immunize eligible children with VFC-supplied vaccine at no charge for the vaccine to the patient or parent. V. Do not charge a vaccine administration fee to the non-Medicaid VFC-eligible children that exceeds the administration fee cap of $16.06 per vaccine dose. For Medicaid VFC-eligible children, accept the reimbursement for immunization administration set by the state Medicaid agency or the contracted Medicaid health plans. VI. Do not deny administration of a federally purchased vaccine to an established patient because the child’s parent/guardian/individual of record is unable to pay the administration fee. Please Note: The term “established patient” applies only to private providers enrolled in the VFC Program. FQHCs/RHCs must administer VFC vaccine to any VFC-eligible children who present for immunization services at their facilities. VII. Distribute the most current Vaccine Information Statements (VIS) each time a vaccine is administered and maintain records in accordance with the National Childhood Vaccine Injury Compensation Act (NCVIA), which includes reporting clinically significant adverse events to the Vaccine Adverse Event Reporting System (VAERS). VIII. Comply with the requirements for ordering, vaccine accountability, and vaccine management. Agree to operate within the VFC Program in a manner intended to avoid fraud and abuse. I assume responsibility for the proper handling and storage of VFC-provided vaccine after delivery to my facility and understand that I may have to pay for vaccine wastage due to neglect. IX. The grantee or the provider may terminate this agreement at any time for personal reasons or failure to comply with these requirements. If the provider chooses to terminate the agreement, he or she agrees to properly return any unused VFC Program vaccine.
*I have read and agree to the terms and conditions:
*Medical Director or equivalent (must be a State of Florida licensed M.D., D.O., P.A., or A.R.N.P.):

*License number:

Please provide any questions or comments here:

*To confirm this is a valid application, please enter the number in the box below:

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