2013 Vaccines For Children Program Enrollment and Profile Form For State Use Only.

VFC # ______________

OSIIS # _________

Enrollment Information Today’s Date: Physician: Last Name

First Name

MI

Clinic Name: Address: Street

Telephone:

(

)

-

City

Fax: (

County

)

State

Zip Code

-

Email Address: Medical License Number:

Medicaid Provider Number:

Federal Employer Identification Number: Does your clinic participate in the Oklahoma State Immunization Information System (OSIIS)? Is your practice/clinic a Federally Qualified Health Center (FQHC)? Is your practice/clinic a Rural Health Clinic (RHC)?

Yes Yes Yes

No No No

To participate in the Vaccines For Children (VFC) program and receive federally procured vaccine provided to my facility at no cost, I agree to the following conditions, on behalf of myself and all other practitioners, nurses and others associated with this medical office, group practice, managed care organization, community/migrant/rural clinic, health department, or other health delivery facility of which I am the physician-in-chief or equivalent: 1. Screen patients and administer VFC program-purchased vaccine only to a child (18 years of age and younger) who qualifies under one or more of the following categories: a) is an American Indian or Alaskan Native; b) enrolled in Medicaid; c) has no health insurance; or d) has health insurance that does not pay for the cost of vaccine. a. Patients who have health insurance that does not pay for the cost of vaccine may only receive VFC-purchased vaccine at a County Health Department, Federally Qualified Health Center, Rural Health Clinic and/or a Deputized Provider with a current CDC approved Memorandum of Understanding dated after October 1, 2012 on file with the Oklahoma State Department of Health Immunization Service. Deputized Providers agree to include “underinsured” as a VFC eligibility category and vaccinate walk in VFC-eligible underinsured children. 2. Administer VFC vaccines only to eligible children in accordance with the immunization schedule, dosages, and contraindications established by the Advisory Committee on Immunization Practices (ACIP) and the VFC resolutions issued by the ACIP. Any exceptions to this practice must be based on a) my medical judgment, in accordance with accepted medical practice; or b) a reasonable belief that a specific requirement contradicts the law in my state pertaining to religious or any other exemptions. 3. Document all administered vaccines into OSIIS. Maintain parent/guardian responses to VFC eligibility in OSIIS, or on the Patient Screening Record form or equivalent record, for a period of 3 years. I will make such records available to the State or the Department of Health and Human Services (DHHS) upon request. 4. Not impose a charge for the cost of the vaccine.

5. Not charge a vaccine administration fee to the non-Medicaid VFC-eligible children that exceeds the administration fee cap of $19.58 per injection of vaccine. 6. Not deny administration of a federally procured vaccine to a patient because the child’s parent/guardian/individual on record is unable to pay the administration fee. For Medicaid VFC-eligible children, accept the reimbursement for immunization administration set by the state Medicaid agency or the contracted Medicaid health plan. 7. Provide the most current written vaccine information statements (VIS) and maintain records in accordance with the National Childhood Vaccine Injury Act, which includes reporting clinically significant adverse events to the Vaccine Adverse Events Reporting System. 8. Comply with the requirements for ordering, vaccine accountability, and vaccine management. I agree to operate within the VFC program in a manner intended to avoid fraud and abuse. I understand that I will comply with the Centers for Disease Control and Prevention (CDC) Recommendations for Storage and Handling of Vaccine, including use of digital data loggers with detachable probes that record and store temperature information at frequent programmable intervals for 24 hour temperature monitoring. In the event that vaccine obtained through the VFC Program is wasted due to negligence and/or improper vaccine storage and handling practice, or I am unable to account for the vaccine, OSDH has the option to require that I replace vaccine dose for dose at my own expense. Vaccine shipments will be suspended until proper procedures are implemented in any of these situations. No dorm style refrigerators are permitted for the storage of vaccine. Stand alone refrigerator and stand alone freezer units suitable for vaccine storage are recommended and may be a future requirement of the VFC Program. 9. OSDH does not allow a Provider to borrow VFC vaccine and administer to a child who is not VFC eligible. I understand that OSDH will require VFC vaccine be replaced dose for dose at my own expense if I inadvertently administer VFC vaccine to a child not VFC eligible. 10. Share immunization records of any VFC patient seen in my practice with the local health department or other practices upon request. 11. Meet with VFC Program staff to discuss VFC compliance, quality assurance, immunization coverage, clinical assessment findings and issues related to VFC patients. Certification of annual provider training is required. VFC program staff may make an unannounced quality assurance visit to providers. 12. Utilize the VFC Program’s nursing resources if needs are identified to obtain clinical training for my staff on vaccine storage, immunization schedule interpretation, and vaccine administration techniques. 13. The State may terminate this agreement at any time for failure to comply with these requirements or I may terminate the agreement at any time for personal reasons. If I choose to terminate the agreement I will return any unused VFC vaccine. _________________________________________________ Physician/NP/PA (Please type or print physician’s name)

Physician’s Signature/NP/PA

Date

This record is to be submitted to and kept on file at the Oklahoma State Department of Health and must be updated in accordance with State policy. For State Use Only (enter date in only one box): Date Certified for VFC

/ MM

/ DD

Date Certified for Vaccine Purchased YYYY

/ MM

DD

/ YYYY

Under a Federal Contract, Excluding VFC

The following information is provided for not-for-profit providers who may need to report VFC vaccine in their Schedule of Expenditures of Federal Awards. CFDA NO: 93.268 CFDA Title: Immunization Grants

Federal Award Name: Immunization and Vaccines for Children Grants

Federal Award Number: please contact the program for the current number Federal Award Year: CY 2013 Please print or type the names and medical license numbers of the other health care providers who may administer vaccine. It is not necessary to include the names of all staff that administer vaccine, but rather, only those who possess a medical license or are authorized to write prescriptions.

Additional Providers Within The Practice Clinic Name: __________________________________________________________________________

Last Name, First, MI

Medical License No.

Title (MD, DO, ND, NP,PA) (Provider must have prescription writing privileges)

Specialty (Peds, Family Med, GP Other [specify])

Title (MD, DO, ND, NP,PA) (Provider must have prescription writing privileges)

Specialty (Peds, Family Med, GP Other [specify])

Title (MD, DO, ND, NP,PA) (Provider must have prescription writing privileges)

Specialty (Peds, Family Med, GP Other [specify])

Title (MD, DO, ND, NP,PA) (Provider must have prescription writing privileges)

Specialty (Peds, Family Med, GP Other [specify])

Title (MD, DO, ND, NP,PA) (Provider must have prescription writing privileges)

Specialty (Peds, Family Med, GP Other [specify])

Title (MD, DO, ND, NP,PA) (Provider must have prescription writing privileges)

Specialty (Peds, Family Med, GP Other [specify])

Title (MD, DO, ND, NP,PA) (Provider must have prescription writing privileges)

Specialty (Peds, Family Med, GP Other [specify])

Medicaid Provider No.

Last Name, First, MI

Medical License No.

Medicaid Provider No.

Last Name, First, MI

Medical License No.

Medicaid Provider No.

Last Name, First, MI

Medical License No.

Medicaid Provider No.

Last Name, First, MI

Medical License No.

Medicaid Provider No.

Last Name, First, MI

Medical License No.

Medicaid Provider No.

Last Name, First, MI

Medical License No.

Medicaid Provider No.

Provider Profile Information All State-approved public and private health care providers participating in the Vaccines For Children (VFC) Program must complete this form. This document provides shipping information and helps the State determine the amount of vaccine to be supplied through the VFC Program. This form also may be used to compare estimated vaccine needs with actual vaccine supply. The State Health Department must keep this form on file with the Provider Enrollment Form. The Provider Profile form must be updated annually or more frequently if 1) the number of children being served changes, or 2) the status of the facility changes (e.g., private provider becomes an agent of a Federally Qualified Health Center).

1. Vaccine Delivery Address: _______________________________________________________ Street (No P.O. Boxes)

_________________________________________ City, State

2. Contact Person (1) : _____________________________ __________________________________ Last

First

_______________________________________________________________ Title

Contact Person (2) : _____________________________ __________________________________ Last

First

_______________________________________________________________ Title

3. Person completing this form (if different than Contact Person): ________________________________ _______________________________ Last

First

_______________________________________________________________ Title

4. Office Hours: Mon _______ Tues _______ Wed _______ Thur _______ Fri _______ Sat _______ 5. Days and Times Vaccine May be delivered if different than office hours. Mon _______ Tues _______ Wed _______ Thur _______ Fri _______ Sat _______ 6. Is the office closed for lunch?

Yes

No

If yes, when? ______________

7. Type of Facility: A. Public Health Department

E. Federally Qualified Health Center (FQHC)

B. Public Hospital

F. Rural Health Clinic (RHC)

C. Private Practice (Individual or Group) D. Private Hospital

G. Other Public Facility _______________________________ H. Other Private Facility ______________________________

8. Vaccine Need: (Note: The following information must be based on data and not estimates. Please document the data source for this information in the boxes provided.) Part A. For the 12 month period beginning January 1, 2013 project the number of children who will receive vaccinations at your health facility, by age group.