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Vaccines For Children Program
Bureau of Immunization
NYC DOHMH F
455 1st Avenue Room 100J
New York, New York 10016
Phone: (212) 447-8175 Fax: (212) 447-8196
VACCINE RECIPIENT AGREEMENT
In order to participate in the NYC Vaccines for Children (VFC) Program and/or receive Federally/State/City
procured vaccines provided to me at no cost, I and all practitioners employed by this medical office, group practice,
HMO, health department, community/migrant/rural clinic, or other entity of which I am the physician-in-charge
or equivalent, agree to the following:
1. I will ask the child’s parent(s) or guardian(s) if the child (18 years and under) is eligible under one or more of the
following categories before administering vaccines obtained through the NYC VFC Program.
Public vaccine eligible:
• Enrolled in Medicaid or Medicaid Managed Care;
• Uninsured;
• Underinsured: Children who have commercial (private) health insurance but the coverage does not
include vaccines, children whose insurance covers only selected vaccines (VFC-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);
• American Indian or Alaska Native;
• Enrolled in Child Health Plus B (CHPlus B).
For purposes of the NYC VFC Program the following children are NOT considered underinsured:
• Children whose insurance covers a portion of the cost of the vaccine but not the full amount. In this
case providers should consider renegotiating the contract with the insurance company.
• Children whose insurance covers vaccines but have a high deductible and whose deductibles have
not been met.
We recommend that you use the NYC Vaccine Eligibility Screening Form to complete this mandatory screening
requirement. A record of the responses given from the parent(s) or guardian(s) must be retained in the patient’s
permanent medical record.
2. I will make VFC eligibility information available to the New York City Department of Health and Mental
Hygiene and/or the US Department of Health and Human Services (DHHS) if requested. This information will be
maintained for a minimum of 3 years.
3. I will comply with the appropriate immunization schedule, age, dosage, and contraindications that are established
by the Advisory Committee on Immunization Practices (ACIP), and included in the VFC program, unless,
a. In making a medical judgment in accordance with accepted medical practice, I deem such compliance
to be medically inappropriate or;
b. The particular requirements are not in compliance with the law of NYS, including State laws relating to
religious or other exemptions.
4. I will maintain a copy of the appropriate Vaccine Administration Record (VAR) in the patient’s permanent
medical record for a minimum of 3 years. If the clinic chooses to use their own vaccine administration record
form, it must contain the following NYC DOHMH VFC required information: the name, address and title of the
person who administered the vaccine, date of administration, site of administration, vaccine manufacturer, lot
number, and the expiration date of the vaccine administered.
Revised 8/21/2009 Page 1 of 2
5. I will purchase vaccines for privately insured patients (non-VFC eligible) and I will present invoices for
purchased vaccines upon request by the Bureau of Immunization staff or I will be able to explain how vaccines
for ineligible VFC patients are acquired.
6. I will provide the most current Vaccine Information Statements (VIS) each time a vaccine is administered and
maintain records in accordance with the National Childhood Vaccine Injury Act, including reporting clinically
significant adverse events to the Vaccine Adverse Event Reporting System (VAERS). Additionally, every
instance when VIS is given it should be documented in the patient’s permanent medical record: which specific
VIS was given (e.g.: MMR), the date of publication of the VIS, and the date the VIS was provided.
7. I will not charge for vaccines given to NYC VFC eligible children. A vaccine administration fee no greater than
the current State Medicaid program reimbursement amount of $17.85 may be charged to non-Medicaid VFC
eligible children. An eligible child cannot be denied vaccine due to the inability of the child’s parent or
guardian to pay the vaccine administration fee. A sign that states this policy must be displayed within the
patient waiting area.
8. I will comply with the NYC VFC Program requirements for ordering vaccines. I understand that I must comply
with the NYS Public Health Law 2168 of reporting to the Citywide Immunization Registry (CIR) all doses of
vaccines administered regardless of insurance status or VFC eligibility. Additionally, I will comply with
applicable federal and state laws regarding fraud (an intentional deception or misrepresentation that could result in
some unauthorized benefit to oneself or some other person) and abuse (practices that are inconsistent with sound
fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are
not medically necessary).
9. I will store and handle vaccines in accordance with each vaccine manufacturer/VFC Program guidelines and in a
manner to prevent abuse, spoilage, and wastage.
10. I must allow the NYC DOHMH, Immunization staff to conduct site visits to perform on site evaluation, check
vaccine storage and handling, check vaccine inventories, and accountability as mandated by the Centers for
Disease Control and Prevention (CDC) and best practices to prevent fraud and abuse.
11. I agree to operate within the VFC program guidelines in a manner intended to avoid fraud and abuse.
12. I will be responsible for returning all publicly purchased vaccines if requested by the NYC DOHMH, Bureau of
Immunization, in accordance with its instructions.
13. I may terminate my enrollment in the VFC program for personal reasons or the DOHMH may terminate
enrollment for failure to comply with the requirements set in this Vaccine Recipient Agreement.
Provider Statement:
I certify, by my signature, that I have read and agree to the requirements listed above pertaining to participation
in the NYC Vaccines for Children Program.
_______________________________________________________________________________
Provider Signature Title
______________________________________________________________________________
Print Full Name Date
Reviewed during Site Visit on Date: _______________________
Reviewed with _________________________________________
Reviewer______________________________________________
Revised 8/21/2009 Page 2 of 2
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