2018 MnVFC Program Provider Agreement

  • All sites enrolled in the MnVFC program must submit a signed MnVFC Program Provider Agreement by Nov. 30 each year.
  • Complete the MnVFC Program Provider Agreement, including the list of additional providers in your practice, and have your medical director sign it.
  • The site must indicate the immunization manager and vaccine coordinator have completed the required annual MnVFC online training by marking the appropriate circle on this agreement.
  • Ordering privileges may be suspended if you do not submit the MnVFC Program Provider Agreement by Nov. 30, 2017.
  • If your site practices the replacement method of vaccine management, you must also sign the Replacement Method of Vaccine Management Agreement by Nov. 30 each year. This agreement is available on Required Annual Reports and Trainings.

Site Information* Site Information*
Provide shipping information if it is different than the site address above. Provide shipping information if it is different than the site address above.
Medical Director or Equivalent* The official MnVFC 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 MnVFC providers with the responsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement. (Employer identification number is an optional field.) Medical Director or Equivalent*

The official MnVFC 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 MnVFC providers with the responsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement.

(Employer identification number is an optional field.)
Enter the following information for the MnVFC immunization manager.* Enter the following information for the MnVFC immunization manager.*
Has this person completed the annual MnVFC online training?* Has this person completed the annual MnVFC online training?*
Enter the following information for the MnVFC vaccine coordinator.* Enter the following information for the MnVFC vaccine coordinator.*
Has this person completed the annual MnVFC online training?* Has this person completed the annual MnVFC online training?*

* All fields for the site information, medical director, immunization manager, and vaccine coordinator above are required to continue the online agreement. The employee identification number (EIN) is an optional field.

Please note: You will need to list all licensed health care providers (MD, DO, NP, PA) at your site who have prescribing authority at the end of this agreement.

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