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Bureau of Immunization: Immunizations Across the Lifespan
A.G. Holley State Hospital Epidemiology STD Tuberculosis & Refugee Health

Florida Vaccines for Children (VFC) Program

Provider Initial Enrollment Form

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* Indicates required field.

Instructions for applying to the Florida Vaccines for Children Program:
Please Note: Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.
  1. Complete and submit this form. If you have questions or encounter problems completing this form, contact the Florida Vaccines for Children Program at (800) 483-2543 or email FloridaVFC@doh.state.fl.us.
  2. You will recieve a confirmation email with your completed form shown. Print and sign a copy for your records.
  3. Once your application has been reviewed and approved, a representative will contact you to schedule an onsite visit to evaluate project details and requirements, and to verify your refrigerator storage unit. All providers must comply with Vaccine Storage Equipment Requirement prior to participating in the VFC Program.
*I agree to the following:
I have a certified, calibrated thermometer.
I have a stand-alone, two-door refrigerator/freezer or equivalent unit.
I will notify the VFC Program when the primary person responsible for vaccine management changes.
 
Provider Information
*Name of physician's office, practice, or clinic: *Date:
   
*Shipping Address (must be a street address, no P.O. boxes):
*County:
*City: *Zip Code:
*Primary Name of Person Responsible for vaccine: *Email address:
*Secondary Name of Person Responsible for vaccine: *Email address:
   
Mailing address (if different from shipping information):
 
 
City: Zip code:
*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)
       
*Medical License Number:
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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.
Delivery instructions: Between the hours of 8 AM and 5 PM, your local time, write the days of the week and times you may receive vaccine deliveries:
Day of the Week *Opening Time Closed for Lunch Open after Lunch *Closing Time
Monday
Tuesday
Wednesday
Thursday
Friday

Please Note: It is the provider's responsibility to notify the VFC Program in advance if the offices will be closed during the days and times which are normally open for business. You can reach a VFC representative at (800) 483-2543, option 6.
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VFC Eligibility Section
*In a 12-month period, estimate the number of VFC children, by age and eligibility, which 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" category, total 9.) 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
Uninsured
American Indian/Alaskan Native
Underinsured/FQHC*
(has health insurance but it does not cover immunizations)
Not Eligible**
Total

*To be VFC-eligible, underinsured children must be vaccinated through a Federally Qualified Health Center or Rural Health Center.
**These children are not eligible for VFC vaccines.
 
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Provider List Section

List of Health Care Providers Licensed to Administer Vaccines

Instructions: Use this form to list all health care providers at your facility licensed to administer vaccines. If additional space is necessary, email the list of additional provider to FloridaVFC@doh.state.fl.us and include the contact name on the application.
*Last name: *First name: MI: *Title (MD, PA, etc.):
*Medical license number: *Speciality (pediatrics, family medicine, etc.):
*Medicaid Number: *National Provider ID (NPI):
Last name: First name: MI: Title (MD, PA, etc.):
Medical license number: Speciality (pediatrics, family medicine, etc.):
Medicaid Number: National Provider ID (NPI):
Last name: First name: MI: Title (MD, PA, etc.):
Medical license number: Speciality (pediatrics, family medicine, etc.):
Medicaid Number: National Provider ID (NPI):
Last name: First name: MI: Title (MD, PA, etc.):
Medical license number: Speciality (pediatrics, family medicine, etc.):
Medicaid Number: National Provider ID (NPI):
Last name: First name: MI: Title (MD, PA, etc.):
Medical license number: Speciality (pediatrics, family medicine, etc.):
Medicaid Number: National Provider ID (NPI):
Last name: First name: MI: Title (MD, PA, etc.):
Medical license number: Speciality (pediatrics, family medicine, etc.):
Medicaid Number: National Provider ID (NPI):
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Submit Application
By pressing "Submit" you agree to the following terms and conditions:
*I have read and agree to the terms and conditions:
*Name of Medical Lead MD, DO, ARNP, or PA:
Please Note: Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.
*License number: *License type: *Email Address:
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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