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Program Enrollment

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 (800) 483-2543.

* Indicates required field.

Instructions for applying to the Florida Vaccines for Children Program (VFC):

Please Note: Under Florida law, email addresses are public records. If you do not want your email 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.

Complete and submit this form. If you have questions or encounter problems completing this form, contact the State VFC Program at (800) 483-2543 or email FloridaVFC@doh.state.fl.us.
You will recieve a confirmation email with your completed form shown. Print and sign a copy for your records.(Some email providers filter messages based on content, subject line, or the sender's address and may put your email into the spam or junk mail folder. Please make sure FloridaVFC@doh.state.fl.us is on your "approved sender" list or "whitelist" and/or in your "address book.")
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:

Yes	No	I have a certified, calibrated thermometer.
Yes	No	I have a stand-alone, two-door refrigerator/freezer or equivalent unit.
Yes	No	I will notify the VFC Program when the VFC Program Coordinator, who is 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:

*VFC Program Coordinator:

*Email address:

*Back-Up VFC Program Coordinator:

*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:

	Doctor's Clinic	Birthing Hospital	Juvenile Correctional Center
	Hospital Clinic	Indian Tribes	Nurse Practitioner
	County Health Department	School Clinic	Walk-In Clinic
	Federally Qualified Health Center	Community Health Center	Other (specifiy)

*Medical License Number:

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Delivery Infomation Section

Please note: This section is very important. It provides necessary shipping information.

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 Program representative at (800) 483-2543, option 6.

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VFC Program 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. Please enter 0 in categories you do not expect to immunize.) 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 an FQHC, RHC, or under an approved deputization agreement.
***These children are not eligible for VFC Program vaccines.

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Vaccine Management in Florida SHOTS Section

List personnel, in addition to the VFC Program Coordinator and the Back-Up Coordinator, and place a checkmark for the requested permissions to manage and order your VFC Program vaccine in Florida SHOTS. All personnel must have a Florida SHOTS user ID to access VFC Program functionality. System User IDs can only be created by your local organization administrator or the Florida SHOTS Help Desk at (877) 888-7468.

Personnel Name	Florida SHOTS System User ID (yes/no)	Update Inventory (Apply pending receipts to inventory)	Can See Orders (View Only for Order Status)	Can Update Orders (Create/Modify VFC Program Vaccine Order Requests)

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Provider List Section

List of Healthcare Providers Licensed to Administer Vaccines

Instructions: Use this form to list all healthcare 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:
In order to participate in the Vaccines for Children (VFC) Program and/or to receive other publicly funded 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 medical director or equivalent, agree to the following: I. Screen patients and document eligibility status at all immunization encounters for eligibility and administer VFC Program-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 Program-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 Program vaccine only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputization agreement. 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 (3) years and make these records available to public health officials including the state or Department of Health and Human Services (DHHS) upon request. IV. Immunize eligible children with VFC Program-supplied vaccine at no charge for the vaccine to the patient or parent. V. Not charge a vaccine administration fee to the non-Medicaid VFC Program-eligible children that exceed the administration fee cap of $24.01 per vaccine dose. For Medicaid VFC Program-eligible children, accept the reimbursement for immunization administration set by the state Medicaid agency or the contracted Medicaid health plans. VI. 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. VII. Distribute the 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 vaccine ordering, vaccine accountability, and vaccine management. Agree to operate within the VFC Program in a manner intended to avoid fraud and abuse. VFC Program providers may not store federally purchased vaccine in dormatory-style refrigerators at any time. Return all spoiled/expired public vaccines to CDC's centralized vaccine distributor within six (6) months of spoilage/expiration. I assume responsibility for the proper handling and storage of VFC Program-provided vaccine after delivery to my facility and understand that I may have to pay for vaccine wastage due to neglect. IX. Participate in VFC Program compliance site visits, storage and handling unannounced visits, and other educational opportunities associated with VFC Program requirements. X. Pharmacists who enroll as VFC Program providers must have staff with statutory authority to immunize available and cannot refuse to vaccinate VFC Program-eligible children based on the parent's inability to pay the administration fee. XI. Enroll in the Florida State Health Online Tracking System (SHOTS), the statewide immunization registry, in order to place vaccine orders. Participation in Florida SHOTS will facilitate direct ordering of vaccine by VFC Program providers in the future. If you do not have a Florida SHOTS account, complete an enrollment form online at https://www.flshots.com/flshots/enroll/applicantquestions.html. If you do not know if you have a Florida SHOTS account, contact the Florida SHOTS help desk at 1 (877) 888-7468. XII. The VFC Program 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. All providers must comply with Vaccine Storage Equipment Requirement prior to participating in the VFC Program. Providers are required to have certified, calibrated thermometers, and stand-alone, two-door refrigerator/freezer units.
*I have read and agree to the terms and conditions:
*Name of Medical Director or equivalent MD, DO, NP, PA, or PharmD:

*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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This page was last modified on: 04/8/2013 03:31:29

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