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Provider Profile and Enrollment Forms - immunizenkycom

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					KENTUCKY IMMUNIZATION PROGRAM VACCINES FOR CHILDREN PROGRAM 2009 PROVIDER ENROLLMENT Provider name: ___________________________________VFC PIN # _______________________ County ______________________ Address ______________________________________________ City, State and Zip Code: _____________________________________________________________ Phone (_______) ____________________ ext.________ Fax (_______)________________________ E-mail address ______________________________________________________________________ Employer Identification Number ________________________________________________________
(Federal tax ID #)

Is your clinic a Federally Qualified Health Center (FQHC)? Yes _____ No _____
(If yes, a copy of the certificate must be included with this form.)

Is your clinic a Rural Health Clinic? Yes _____ No _____
(If yes, a copy of the certificate must be included with this form.)

1. Shipping contact name ____________________________________________________________ Last Name First 2. Secondary shipping contact name ____________________________________________________ Last Name First To participate in the Vaccines for Children (VFC) program to receive federally procured vaccine provided to my facility at no cost, I agree to the following conditions on behalf of myself and all practitioners associated with this medical office, group practice, Health Maintenance Organization, community/migrant/rural clinic, health department, or other health delivery facility of which I am the physician-in-chief or equivalent:
1. I will screen patients and administer VFC program-purchased vaccine only to a child (< 18 years of age) who qualifies under one or more of the following categories: (a) is on Medicaid (or qualifies through a State Medicaid waiver), or (b) has no health insurance, or (c) is an American Indian or Alaskan Native, or (d) has health insurance that does not pay for the vaccine or are underinsured. Underinsured are children who have private health insurance but the coverage does not include vaccine, 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. (e) A patient that is considered state vaccine-eligible under criteria determined by the Kentucky Immunization Program for vaccine purchased with state funds. Example: universal Hepatitis B birth dose and underinsured patients receiving state supplied vaccines in all provider offices.

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2. I will comply with the appropriate immunization schedule, dosage, and contraindications that are established by the ACIP and included in the VFC Program unless: (a) in my medical judgment and in accordance with accepted medical practice, I deem such compliance to be medically inappropriate or (b) the particular requirement contradicts the law in my state pertaining to religious or other exemptions. * 3. I will maintain parent/guardian/individual of record responses on the Patient Eligibility Screening Record form for a minimum of 3 years. Release of such records will be bound by the privacy protection of federal Medicaid law. 4. If requested, I will make such records available to the Department of Health and Human Services (DHHS) and the Kentucky Cabinet for Health Services. 5. I will immunize eligible children with VFC-supplied vaccine at no charge to the patient for the cost of the vaccine. 6. I will not charge a vaccine administration fee to non-Medicaid VFC eligible children that exceed the administration fee cap of $14.17 per vaccine dose. The Centers for Medicare and Medicaid Services Regional Administration Fee Cap from the 2007 VFC Manual is $14.17 for Kentucky. For Medicaid VFC-eligible children, I will accept the reimbursement for immunization administration set by the state Medicaid agency. 7. I will 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. 8. I will distribute current Vaccine Information Statements (VIS) each time a vaccine is administered and maintain records in accordance with the National Childhood Vaccine Injury Act (NCVIA) which includes reporting clinically significant adverse events to the Vaccine Adverse Event Reporting System (VAERS). 9. I will 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. 10. I will handle and store vaccine in accordance with vaccine package insert instructions, and may be required to reimburse the Immunization Program for the cost of any state vaccines that I receive for which I cannot account or that spoil or expire because of negligence. 11. The state or I 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 all unused VFC vaccine.

___________________________________________________________ Primary Provider, Physician-in-chief, clinic director or equivalent Signature

______________ Date

Please print or type the Primary Provider’s name, Medical License Number, Title, Specialty and Medicaid Provider Number of the primary health providers who may administer vaccine (attach multiple copies of the “Additional Providers Within the Practice” sheet if additional space is needed).
_________________________________________________ Last Name, First, MI ___________________________________ Title (MD, ND, DO, NP, PA) (Provider must have prescription-writing privileges.)

____________________ Medicaid Provider No.

_____________________ Medical License No

_____________________________ Specialty (Peds, Family Med, GP)

This record is to be submitted to and kept on file at the Kentucky Immunization Program and must be updated in accordance with state policy. * The ACIP Immunization Schedule is compatible with the AAP & AAFP recommendations. FOR STATE USE ONLY 2
Date certified for VFC and other vaccine purchased off Federal contracts: ____________________________

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Additional Providers within the Practice
_________________________________________________ Last Name, First, MI ___________________________________ Title (MD, ND, DO, NP, PA) (Provider must have prescription-writing privileges.) _____________________________ Specialty (Peds, Family Med, GP)

_____________________ Medicaid Provider No.

_____________________ Medical License No

_________________________________________________ Last Name, First, MI

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

_____________________ Medicaid Provider No.

_____________________ Medical License No

_____________________________ Specialty (Peds, Family Med, GP)

_________________________________________________ Last Name, First, MI

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

_____________________ Medicaid Provider No.

_____________________ Medical License No

_____________________________ Specialty (Peds, Family Med, GP)

_________________________________________________ Last Name, First, MI

___________________________________ Title (MD, ND, DO, NP, PA) (Provider must have prescription-writing privileges.) _____________________________ Specialty (Peds, Family Med, GP)

_____________________ Medicaid Provider No.

_____________________ Medical License No

_________________________________________________ Last Name, First, MI

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

_____________________ Medicaid Provider No.

_____________________ Medical License No

_____________________________ Specialty (Peds, Family Med, GP)

P/Epi/CommDisease/Immunize/VFC/VFCProviderManual&Forms/Enrollmentcontract2008.doc 3 8/15/2007

2009 PROVIDER PROFILE VACCINES FOR CHILDREN PROGRAM
1. Kentucky Vaccines for Children PIN number: __________________________________
2. Provider name: __________________________________________________________

<1 Year 3. For the next 12-month period or one year, calculate the number of children who will receive vaccines supplied by VFC at your practice/clinic: 4. Of the total number entered in #3 above, how many children are: A) Enrolled in Medicaid (Passport included) B) Without health insurance or uninsured: C) American Indian or Alaska Native D) Insurance that does not cover immunizations or underinsured: E) KCHIP TOTAL (Items A-E): (Total should be the same amount listed in question 3 above, unless you are a hospital. * )

1-6 Years

7-18 Years

Totals

*FOR HOSPITALS ONLY: Kentucky is a universal Hepatitis B birth dose state. Your numbers on the above chart will not match due to insured patients receiving the Hepatitis B birth dose. Person completing this form: _________________________________________ Date: ____________________
P/Epi/CommDisease/Immunize/VFC/VFC ProviderManual&Forms/ProviderProfile2008.doc

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VACCINES FOR CHILDREN PROGRAM

2009 FREEZER SURVEY The Varicella (Chickenpox, brand name Varivax) and/or Measles, Mumps, Rubella and Varicella (MMR-V, brand name ProQuad) vaccines are heat sensitive, live virus vaccines. It is vitally important that all providers ensure that: 1) enough freezer space is available in each office to store an adequate supply of these vaccines, keeping in mind that these vaccines are packaged in single dose vials, and is 10 vials to a pack, and 2) each office’s freezer compartment must be able to maintain an average temperature of +5 F or colder to ensure vaccine potency. This temperature can be maintained in the freezer compartment of any frost-free, kitchen size refrigerator/freezer or freezer only unit. Because of the thermal labile conditions of this vaccine, Merck and Company, Inc. will be shipping your Varivax and ProQuad vaccine orders directly to your office. Ordering procedures for these vaccines, however, will not change from the way you order other childhood vaccines using the Vaccines for Children Vaccine Activity and Order Worksheet. A. VFC PIN #: ___________________________________________________________________ B. Provider Name: ________________________________________________________________ C. Vaccine Delivery Address (No P.O. Boxes) __________________________________________
(Street Address) _____________________________________________________________________________________________ (City) (State) (Zip Code) Please list hours of operation for your office below: REGULAR HOURS OPEN CLOSE

OFFICE CLOSED FOR OTHER REASONS (LUNCH, ETC.)

MONDAY TUESDAY WEDNESDAY THURSDAY Contact Person(s) Name: _________________________________________________________ Telephone Number: ____________________ ext. ________Fax Number: _________________ Will you be ordering one or both vaccines? __________________________________________ Do you have a freezer capable of remaining below +5 F (-15 C)? _______________________ Are there any special shipping instructions? __________________________________________ _____________________________________________________________________________ I. Do you have a temperature-recording device (a thermometer that records the temperature of your freezer on paper) currently in your freezer? __________________________________________ J. How often is your freezer temperature monitored? _____________________________________ K. If you WILL be ordering the vaccines, and you do NOT have a freezer capable of maintaining +5 F (15C), what is the approximate date you plan on obtaining this freezer? ______________________________________________________________________________ FOR IMMUNIZATION PROGRAM STAFF USE ONLY: ________ Approved for freezer vaccines. ________ NOT approved for freezer vaccines. Field Staff Signature: _______________________________________ Date: _________________ D. E. F. G. H.

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