Texas Vaccines For Children Program (Tvfc) Provider Enrollment Page 2
ADVERTISEMENT
1
2
3TEXAS VACCINES FOR CHILDREN PROGRAM
PROVIDER PROFILE FOR PIN ___ ___ ___ ___ ___ ___
Is your facility a Federally Qualified Health Center, Migrant Health Clinic, or Rural Health Clinic?
(Circle one)
YES
NO
√
Type of Clinic: (
check one)
!
!
Public Health Department/District
Private Hospital
!
!
Public Hospital
Private Practice (Individual or Group)
!
!
Other Public Clinic
Other Private Clinic
PATIENT PROFILE:
Please enter the number of children for each of the following categories and by
age group who will be vaccinated at your clinic in the next 12-month period.
NUMBER OF CHILDREN IN EACH CATEGORY
< 1 year old
1 - 6 years 7 - 18 years
Total
Enrolled in Medicaid.
Uninsured. (Note: Children enrolled in Health Maintenance Organizations
are considered insured)
American Indians.
Alaskan Natives.
Underinsured. (Has health insurance that Does Not pay for vaccines, has
a co-pay or deductible the family cannot meet, or has insurance that
provides limited wellness or prevention coverage.)
(For Public Health Clinic Use ONLY) Children who do not meet any of
the above criteria, but still receive vaccinations at public health clinics.
Children who receive benefits from the Children’s Health Insurance Plan
(CHIP).
Children who are vaccinated in your practice, but are NOT TVFC-eligible.
TOTAL PATIENTS: (Add columns)
TEXAS VACCINES FOR CHILDREN PROGRAM PROVIDER LIST
Please list all individuals within the practice who will be administering TVFC supplied vaccine.
Last Name
First Name
Middle
Title (M.D., D.O.,
National
Medical
Specialty
(List provider who signed
Initial
N.P., P.A., R.N.,
Provider
License
(Family Medicine,
Provider Enrollment Formfirst)
L.V.N., M.A.)
Identification
Number
Pediatrics, etc.)
Texas Department of State Health Services
Stock Number E6-102
Immunization Branch
Revised 12/2007
ccc
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal