____ Dear Health Care Provider Attached please find provider

_______________________________________________________________________________________________________ Dear Health Care Provider: Attached please find provider enrollment forms for the NM Vaccines for Children Program: 1) 2) 3) 4) 5) 6) 7) Provider Enrollment Agreement Provider Profile Benchmark Chart* State Pharmacy License Form Varicella Vaccine Certification Form Vaccine Ordering & Inventory Form Please also submit: Copy of current NM State Board of Pharmacy Clinic License OR Copy of NM Board of Medical Examiners License (if chief provider is an MD) OR Copy of NM Board of Osteopathic Medical Examiners License (if chief provider is a DO) OR Copy of NM Board of Nursing – Nurse Practitioner’s License (only if chief provider is a NP) *Please complete the benchmark chart if you do not have adequate data to complete the provider profile. If you are a new provider or have a new practice, please estimate the number of patients you will serve to the best of your ability (this info is used to help us order adequate vaccine stock for our Pharmacy). Please submit to: NM VFC Program – Immunizations Attn: Carly Christian New Mexico Department of Health 1190 St. Francis Drive, S-1262 Santa Fe, NM 87505 Fax: (505) 827-1741 If you have questions, please call Carly Christian at (505) 827-2898. _______________________________________________________________________________________________________ 2003 PROVIDER ENROLLMENT NM VACCINES FOR CHILDREN PROGRAM VFC PIN #:___________ Chief Provider's Name:_________________________ ____ _____________________________________ First MI Last Facility Name:__________________________________________________________________________________ Address:________________________________ Street Telephone: ( ) ________________Fax: ( ________________________ City ________ State __________ Zip Code )____________________Email:______________________________ 1. Contact Name:_______________________________ ___________________________________________ First Last 2. Contact Name:_______________________________ ___________________________________________ First Last To participate in the NM 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 the 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 (<19 years of age) who qualifies under one or more of the following categories: a) is an American Indian or Alaska Native; b) is on Medicaid/Salud/CHIP; c) has no health insurance; or d) has private insurance. All children, <19 years of age, with or without insurance, are eligible to receive vaccines from the NM VFC program. 2. I will administer VFC vaccines only to children in eligible age cohorts for each vaccine, as set by the Advisory Committee on Immunization Practices (ACIP) in VFC resolutions. 3. I will maintain parent/guardian responses on the Immunization Record Part B form for a period of 3 years. Release of such records will be bound by the privacy protection of the federal Medicaid law. 4. 5. If requested, I will make such records available to the state or the Department of Health and Human Services (DHHS). I will participate in VFC CASA/AFIX clinic assessments as requested. I will comply with the appropriate immunization schedule, dosage, and contraindications that are established by the Advisory Committee on Immunization Practices (ACIP). I will administer VFC vaccines to children in eligible age cohorts for each vaccine, as set by the ACIP in VFC resolutions. I will distribute current Vaccine Information Statements and maintain records in accordance with the National Childhood Vaccine Injury Act, which includes reporting clinically significant adverse events to the Vaccine Adverse Event Reporting System. I will not impose a charge for the cost of the vaccine. I will not accept reimbursement for vaccine received from the NM VFC program. For commercially insured clients of the following health plans, I will zero bill for vaccine received from the NM VFC program: Blue Cross/Blue Shield, Cimarron, Lovelace, Presbyterian. 6. 7. _______________________________________________________________________________________________________ VFC PIN #:_________ 8. I will not impose a charge for the administration of the vaccine that is higher than the maximum fee established by the state ($10 per shot in NM). 9. I will not deny administration of VFC vaccines to a child because the child’s parent/guardian/individual of record is unable to pay the shot administration fee. 10. I will comply with the state’s requirements for ordering vaccines and with other NM VFC program requirements. 11. I will maintain the cold chain by adhering to instructions as outlined in Recommendations for Handling and Storage of Selected Biologicals. This information is provided to all facilities administering VFC vaccines. 12. I will maintain temperature logs for the refrigerator and freezer. Temperature logs are due monthly to the district VFC coordinator. Submission of monthly temperature logs is a requirement for VFC program participation. 13. I will submit a current vaccine inventory with each vaccine order. 14. I will utilize Immunization Record Part B forms for the purpose of informed consent and data reporting. This record has a section identifying the vaccine recipient's category of eligibility. The original of this record must be maintained by the provider as a medical record for a period of three years. A copy must be forwarded to the state office for database entry within one month of vaccine administration. 15. I will monitor vaccine supply and expiration dates so that overstocked short-dated vaccines may be redistributed according to DOH Pharmacy handling and shipping instructions. 16. I will include a Vaccine Transfer Report with any vaccines returned to the DOH Pharmacy for any reason. I will ship back to the DOH Pharmacy all unusable vaccines (expired, wasted, etc.) so that DOH can collect the excise tax refund on returned vaccines. 17. The state or I may terminate this agreement at any time for personal reasons or for failure to comply with these requirements. *Note: The ACIP immunization schedule is compatible with AAP and AAFP recommendations. _______________________________________________ Chief Physician/Primary Provider’s Signature _________________________________________ Date This record is to be submitted to and kept on file at the NM VFC Program and must be updated annually. Please print or type the names and medical license numbers of all health providers (MD, DO, ND, NP, PA only) who may administer vaccines (attach multiple copies of the “Additional Providers Within the Practice” sheet if additional space is needed). __________________________ Last Name, First, MI _________________ Medical License No. _________________ Medicaid Provider No. _________________ ______________________ Title (MD,DO,PA, NP) Specialty (Peds, Family (Provider must have Med, GP, Other (specify) prescription writing privileges) _______________________________________________________________________________________________________ PROVIDER ENROLLMENT (CONTINUED) ADDITIONAL PROVIDERS WITHIN THE PRACTICE Facility Name:__________________________________________________ __________________________ Last Name, First, MI _________________ Medical License No. _________________ Medicaid Provider No. _________________ Medical License No. _________________ Medicaid Provider No. _________________ Medical License No. _________________ Medicaid Provider No. _________________ Medical License No. _________________ Medicaid Provider No. _________________ Medical License No. _________________ Medicaid Provider No. _________________ Medical License No. _________________ Medicaid Provider No. _________________ Medical License No. _________________ Medicaid Provider No. _________________ Medical License No. _________________ Medicaid Provider No. _________________ Medical License No. _________________ Medicaid Provider No. _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) _________________ Title (MD,DO,PA,NP) (Provider must have prescription writing privileges) VFC PIN:____________ ______________________ Specialty (Peds, Family Med, GP, Other (specify) ______________________ Specialty (Peds, Family Med, GP, Other (specify) ______________________ Specialty (Peds, Family Med, GP, Other (specify) ______________________ Specialty (Peds, Family Med, GP, Other (specify) ______________________ Specialty (Peds, Family Med, GP, Other (specify) ______________________ Specialty (Peds, Family Med, GP, Other (specify) ______________________ Specialty (Peds, Family Med, GP, Other (specify) ______________________ Specialty (Peds, Family Med, GP, Other (specify) ______________________ Specialty (Peds, Family Med, GP, Other (specify) __________________________ Last Name, First, MI __________________________ Last Name, First, MI __________________________ Last Name, First, MI __________________________ Last Name, First, MI __________________________ Last Name, First, MI __________________________ Last Name, First, MI __________________________ Last Name, First, MI __________________________ Last Name, First, MI _______________________________________________________________________________________________________ 2003 Provider Profile NM Vaccines For Children Program 1. Today’s Date:_______/_________/______ 2. VFC PIN:__________ All State-approved public and private health care providers participating in the NM Vaccines For Children (VFC) program must complete this form annually. This document provides shipping information and helps the State project the amount of vaccine needed. This form will also be used to compare estimated vaccine needs with actual vaccine supply. The State Health Department must keep this record 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. 3. Chief Provider’s Name:_____________________________________________________________________ 4. Facility Name:_____________________________________________________________________________ 5. Vaccine Delivery Address:___________________________________________________________________ Street (no P.O. Boxes) ______________________________________________________ ____ _______________ City State Zip code 6. Days and Times Vaccine May Be Delivered:_____________________________________________________ 7. Contact Person:____________________________________ First _________________________________________________ Title 8. Telephone No: ( )________________________ 9. Fax No: ( )________________________________ ___________________________________ Last 10. Email:______________________________________________________ 11. Type of Facility (Check only one): A. Public Health Department B. Public Hospital C. Federally Qualified Health Center (FQHC) D. Other Public:____________________________________________ E. Private Practice (Individual or Group) F. Private Hospital G. Other Private:___________________________________________ H. Indian Health Service _______________________________________________________________________________________________________ 2003 PROVIDER PROFILE VFC PIN:_________ 12. 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. 12A. For a 12 month period, project the number of children who will receive vaccinations at your health facility, by age group. <1 Year Old TOTAL CHILDREN NEEDING IMMUNIZATIONS 1 thru 6 Years 7 thru 18 Years b. TOTAL d. a. * * c. * * 12B. Of the total number for each age group entered above, how many children are expected to be NM VFC eligible by category? Please remember that in New Mexico, all children ages <19 years are eligible to receive NM VFC vaccines. All NM children are eligible (with and without insurance). <1 Year Enrolled in Medicaid/ Salud/CHIP No Health Insurance American Indian Has private health insurance TOTAL a* b* *Totals in 12A (a, b, c, d) should equal totals in 12B (a, b, c, d). c* d* 1 thru 6 Years 7 thru 18 Years TOTAL Only two types of data should be used to complete 12A and 12B: benchmarking or provider encounter data. Please indicate which data you are using: Provider Encounter Data (based on actual patient data, NOT estimates) Benchmarking Data (see attached) If you are unable to provide actual encounter data, please complete the attached benchmarking chart. _______________________________________________________________________________________________________ Weekly Immunization Population Benchmark Chart VFC Pin #:________ Facility Name: ____________________________________________ Completed by:______________________________ Phone Number:__________________________ Dates covered in this benchmark chart (one month) ________________ to ___________________ Week of ________(month)________(day)________(year) < 1 Year Old 1-6 Years Old Native American Enrolled in Medicaid/ Salud/CHIP Page _____ of _____ 7-18 Y Has Private Insurance Total Children Who Received Immunizations • • • • (Add column) (Add column) (Add column) Please do not double count children. This is a record of child visits per day, not the number of shots given. If a child is Native American, only count the child in the Native American category. Do not count a Native American child under Medicaid, uninsured or has private insurance. Please complete one form for each week in the one-month period you will benchmark. SEE BACK FOR MORE INSTRUCTIONS ON COMPLETING THIS FORM. _______________________________________________________________________________________________________ For purposes of the annual VFC update, you must complete either the Provider Profile OR the Benchmark Chart. You might choose to do the benchmark instead of the provider profile if you are uncertain about predicting numbers of patients for the profile and opt instead to collect patient information based on data instead of estimates. If you have questions, please call (505) 827-2898. Benchmark Instructions 1. The purpose of benchmarking is to collect patient information based on data, not estimates. 2. Fill in your VFC pin number, facility name, your name and phone number and the dates of your benchmarking. 3. Complete one form for each week in the one-month period you will benchmark. Note the week’s date on each sheet. 4. Place the benchmark form on your refrigerator, at the front desk or another appropriate location. Instruct all staff who give shots or identify ages of patients on how to complete the form. 5. When a patient who is birth through 18 years of age is immunized, enter a mark in the appropriate block. 6. Do not double count children. This is a record of child visits per day, not the number of shots given. 7. Count each child in one category only. If a child is Native American, only count the child in the Native American category. Don’t count a Native American child under Medicaid, uninsured or has private insurance. 8. Every child in your practice who meets the age criteria (0 through 18 years) and who is immunized during the month long time period should be entered by age and insurance status (Native American, Medicaid/Salud/CHIP, uninsured or has private insurance). 9. Remember that in NM, ALL children from birth through age 18 years are eligible to receive VFC vaccine whether or not they have insurance. 10. After you have benchmarked for a week, tally each column by age for the number of children immunized that week. Complete 4 separate weekly benchmark sheets for a total benchmarking time of one month. _______________________________________________________________________________________________________ STATE PHARMACY LICENSE FORM FOR 2003 Federal and state regulations require wholesale drug distributors to maintain current records of their pharmacy account licenses. Name of Facility:______________________________________________ ____________________ VFC PIN Address__________________________ _________________________ ______ ______________ Street City State Zip Code Phone:( )_____________________________ Fax: ( ) ____________________________________ Email:_______________________________________________________________________________ State Pharmacy License (Clinic Permit) License No:_______________ Expiration Date:____________ *Please complete this form and return with a photocopy of your current state pharmacy license. If you are not a public health office, please indicate below your consultant pharmacist’s name and a telephone number where s/he may be reached during working hours. Consultant Pharmacist’s Name:__________________________________________________________ Phone:___________________ Please note: If you are a private provider and do not have a NM State Board of Pharmacy clinic license, you will need to submit a current: • Copy of NM Board of Medical Examiners License (MD) OR • Copy of NM Board of Osteopathic Medical Examiners License (DO) OR • Copy of NM Board of Nursing-Nurse Practitioner's License (only if your chief provider is a NP) _______________________________________________________________________________________________________ VARICELLA VACCINE CERTIFICATION FORM (* UNLESS YOUR FREEZER CAPACITY CHANGES, YOU DO NOT NEED TO RESUBMIT THIS FORM ONCE YOU HAVE BEEN APPROVED TO STOCK VARICELLA VACCINE.) Your freezer must be approved before you can order varicella vaccine. If you have questions about vaccine storage, please call Charles Iddings at (505) 827-2415. DATE FACILITY NAME VFC PIN # CONTACT PERSON PHONE NUMBER E-MAIL ADDRESS 1. I’M INTERESTED INSTOCKING VARICELLA VACCINE AT MY FACILITY. YES NO 2. SIZE OF YOUR REFRIGERATOR/FREEZER. These are acceptable for storing varicella vaccine: A) Full-size refrigerator/freezer (freezer maintains temperature at –15o C/+5o F or colder) B) 3-4 foot refrigerator with sealed freezer compartment and exterior freezer door (freezer maintains temperature at -–5o C/ +5oF or colder C) Commercial: If you have any other type of freezer than those listed above; please indicate: 3. YEAR OF PURCHASE 4. DO YOU HAVE A THERMOMETER IN YOUR FREEZER? YES NO NO 5. DO YOU HAVE A THERMOMETER IN YOUR REFRIGERATOR: YES 6. WHAT ARE YOUR REGULAR OFFICE HOURS? WE WILL BE PROVIDING YOU WITH MORE INFORMATION ON STORAGE OF VARICELLA VACCINE VFC APPROVES THE ABOVE FACILITY FOR VARICELLA VACCINE: YES NO DATE INITIALS _______________________________________________________________________________________________________ VFC Vaccine Ordering & Inventory Facility Name:_______________________________VFC PIN #:_______________________________ Address:_______________________________ Prepared by: ______________________________ City/State/Zip:_______________________________Date Submitted: ___________________________ Telephone #:_________________________________Fax #:____________________________________ IMPORTANT: If the brand you select is not in stock, the Pharmacy will call you to determine if you will accept another brand. #Doses On Hand Lots & Exp. Dates #Dosed Requested Vaccine Comvax (Hep B + Hib) DT (Pediatric)* < 7 Yrs. DTaP _ _ Infanrix _ Any brand Havrix _ Any brand _ _ Daptacel Hep. A (Ped./Adol.) Vaqta Hep. B (Ped./Adol.) _ _ Engerix _ Recombivax 2 dose adolescent series _ Any brand Hib _ ActHib _ Hibtiter _ _ PedvaxHib Any brand IPV (Polio) MMR Pediarix (DTaP + Hep B + IPV) PCV-7 Prevnar pediatric (Pneumococcal Conjugate) PPV-23 Pneumococcal Polysaccharide) Td (Adult) 7 Years + Varicella** * ** All requests for DT must be pre-approved prior to placing order. Call (505) 827-2415 The varicella storage freezer must be approved before placing first order. (505) 827-2415 Mail or Fax to: NM Department of Health Pharmacy P.O. Box 26110 Santa Fe, NM 87502-6110 FAX (505) 827-1064 For questions about your order, call (505) 827-1781 VFC Program Manager: (505) 827-2898 6/03