Vaccines For Children (Vfc) Program Provider Agreement And Profile
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6NEW YORK STATE DEPARTMENT OF HEALTH
FOR DOH USE ONLY Date rec’d:
Bureau of Immunization
Vaccine Program
VFC PIN #
ESP Corning Tower RM 649
Vaccines For Children (VFC) Program
Albany NY 12237–0627
Phone: (800) 543-7468 Fax: (518) 449-6912
Provider Agreement and Profile
New
New Location-Moved Closed Prior Site (Prior VFC PIN#__________)
Annual Renewal VFC PIN#__________
FACILITY INFORMATION
Facility Name
VFC Pin Number
Facility Address
City
County
State
Zip Code
Telephone Number
Fax Number
Email
Shipping Address (if different than facility address)
City
County
State
Zip Code
OFFICE HOURS OF OPERATION
a.m.
a.m.
a.m.
a.m.
:
:
:
:
M
TH
to
to
p.m.
p.m.
p.m.
p.m.
a.m.
a.m.
a.m.
a.m.
:
:
:
:
T
F
to
to
p.m.
p.m.
p.m.
p.m.
a.m.
a.m.
CLOSED
:
:
:
a.m.
:
a.m.
W
to
to
p.m.
p.m
FOR LUNCH
p.m.
p.m.
MEDICAL DIRECTOR OR EQUIVALENT
Instructions: The official VFC registered health care provider signing the agreement must be a practitioner authorized to administer pediatric
vaccines under state law who will also be held accountable for compliance by the entire organization and its VFC providers with the responsible
conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement.
Last Name
First
Middle
Title (MD, DO, NP, PA)
Specialty
Medical License Number
Medicaid or NPI Number
Employer Identification Number (optional)
Provide information for second individual as needed:
Last Name
First
Middle
Title (MD, DO, NP, PA)
Specialty
Medical License Number
Medicaid or NPI Number
Employer Identification Number (optional)
VFC VACCINE COORDINATOR
Primary Vaccine Coordinator Last Name
First
Middle
Telephone Number
Email
Completed annual training
Yes
No Type of training received
Back-Up Vaccine Coordinator Last Name
First
Middle
Telephone Number
Email
Completed annual training
Yes
No Type of training received
DOH-3836 (5/14) page 1 of 6
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