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Vaccines for Children Program FOR NEW ENROLLMENTS OR

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Vaccines for Children Program
Bureau of Immunization
NYC DOHMH
42-09 28
th
Street, 5
th
Floor, CN-21
Queens, New York, 11101-4132
Phone: (347) 396-2404 / Fax: (347) 396-2559
PROVIDER INFORMATION FORM
FOR NEW ENROLLMENTS OR TO UPDATE PROVIDER INFORMATION
To update provider information, please complete the whole form and check the boxes “Updates Made to This Section” when applicable
(Please complete all *required fields & return by fax or mail)
PRACTICE/GROUP PRACTICE/CLINIC/FACILITY NAME:*____________________________________________________________________
PROGRAM STATUS:* New Enrollment OR Currently Enrolled
PIN NUMBER:_______________
FACILITY CODE: ________________
FACILITY CLASSIFICATION: UPDATES MADE TO THIS SECTION
*Practice Type (age group your facility serves): Pediatric (i.e., Child<19) Adult Both
*Funding Class (primary source of funding at this site):
Private Public FQHC
*Sector (describes your organization type)
Private Practice
Setting: In NYC
Specialty: _____________________
OR
Hospital
Setting: ____________________
Specialty: _____________________
OR
Other Medical Facility
Sub Sector: ____________________
Specialty: _____________________
*Sector (describes your organization type)
Public Health Department
Sub Sector: ___________________
Specialty: ___________________
OR
Hospital
Sub Sector: ___________________
Specialty: ___________________
OR
Other Medical Facility
Sub Sector: ___________________
Specialty: ___________________
*Sector
(describes your organization type)
Hospital
OR
Community Health Center
Subsector:
Homeless Center
Drug Rehabilitation
Clinic – Offsite/Satelite
Mobile Unit
School Based Clinic
Other: ___________________
SHIPPING ADDRESS (refers to the address where your vaccines will be shipped): UPDATES MADE TO THIS SECTION
*Address Line1 : ____________________________________________________ Address Line 2: _______________________
*Borough: _________________________________________ *State: New York *Zip Code: __________________
*Telephone Number: ________________________________ Ext. ________________ *Fax: ____________________________
*Email Address: ____________________________________________ Cell Phone: ___________________________________
*Shipping Contact (please only choose one)
:
Physician-In-Charge Vaccine Coordinator Backup Vaccine Coordinator
Additional Contact
SHIPPING HOURS* (days/times when your facility can receive vaccine shipments): UPDATES MADE TO THIS SECTION
First Open Interval
Second Open Interval
From
To
From
To
Monday
Office is closed/no deliveries
Tuesday
Office is closed/no deliveries
Wednesday
Office is closed/no deliveries
Thursday
Office is closed/no deliveries
Friday
Office is closed/no deliveries
Vaccines for Children Program
Bureau of Immunization
NYC DOHMH
42-09 28
th
Street, 5
th
Floor, CN-21
Queens, New York, 11101-4132
Phone: (347) 396-2404 / Fax: (347) 396-2559
PHYSICIAN-IN-CHARGE (PIC) UPDATES MADE TO THIS SECTION
This title refers to the main physician involved with VFC vaccines.
Please note that the PIC can be PIC and VC OR PIC and BVC, but CANNOT be all three (PIC, VC, and BVC).
*First Name: _________________________________________ *Last Name: _________________________________________
Medicaid Provider Name: ____________________________ *NYS Medical License Number: ______________________
Job Title: _________________________________________________________________________________________________
*Address Line 1: _______________________________________________________ Address Line 2: ____________________
*City: __________________________________________ *State: ____New York *Zip Code: ______________________
*Telephone Number: _______________________________ Ext. _______________ *Fax Number: ______________________
*Email Address: __________________________________________________ Cell Phone: _____________________________
VACCINE COORDINATOR (VC) UPDATES MADE TO THIS SECTION
*Type: Physician Non-Physician Vaccine Coordinator is Same as Physician-In-Charge
*First Name: _________________________________________ *Last Name: _________________________________________
Job Title: _________________________________________________________________________________________________
*Address Line 1: ______________________________________________________ Address Line 2: _____________________
*City: _________________________________________ *State: ____New York *Zip Code: _______________________
*Telephone Number: ______________________________ Ext. _______________ *Fax Number: ______________________
*Email Address: __________________________________________________ Cell Phone: _____________________________
BACK-UP VACCINE COORDINATOR (BVC) UPDATES MADE TO THIS SECTION
*Type: Physician Non-Physician Back-up Vaccine Coordinator is Same as Physician-In-Charge
*First Name: _________________________________________ *Last Name: _________________________________________
Job Title: _________________________________________________________________________________________________
*Address Line 1: ______________________________________________________ Address Line 2: _____________________
*City: _________________________________________ *State: ____New York *Zip Code: _______________________
*Telephone Number: ______________________________ Ext. _______________ *Fax Number: ______________________
*Email Address: __________________________________________________ Cell Phone: _____________________________
ADDITIONAL CONTACT (optional) UPDATES MADE TO THIS SECTION
*Type: Physician Non-Physician
*First Name: __________________________________________ *Last Name: ________________________________________
Job Title: _________________________________________________________________________________________________
*Address Line 1: ______________________________________________________ Address Line 2: _____________________
*City: _________________________________________ *State: ____New York *Zip Code: _______________________
*Telephone Number: ______________________________ Ext. _______________ *Fax Number: ______________________
*Email Address: _________________________________________________ Cell Phone: ______________________________
Vaccines for Children Program
Bureau of Immunization
NYC DOHMH
42-09 28
th
Street, 5
th
Floor, CN-21
Queens, New York, 11101-4132
Phone: (347) 396-2404 / Fax: (347) 396-2559
ANNUAL PATIENT NUMBERS* UPDATES MADE TO THIS SECTION
Please report the number of children immunized yearly in each of the categories listed below. Do NOT enter
percentages, symbols, etc. Incomplete information may result in the delay of your enrollment.
Category <1 Year 1-6 Years 7-18 Years > 19 Years
Medicaid/Medicaid Managed Care
Not Insured/No Insurance
American Indian/Alaskan Native
Underinsured*
Child Health Plus B (CHPlus B)
Not Eligible**
TOTAL
*Underinsured – Children who have commercial (private) health insurance but does not cover 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 (when amount is reached, children are categorized as underinsured).
**Not Eligible – Insurance covers all or part of the cost of vaccine.
Type of data used to determine profile:*
Benchmarking
Medicaid Claims Data
Dose Administered
Provider Encounter Data
Registry
Other (specify): _____________________
PRACTITIONER LIST* UPDATES MADE TO THIS SECTION
Please list all immunizing staff at your facility; including anyone you listed above (attach additional sheets if
necessary).
First Name* Last Name* Degree* Medicaid Provider # NYS Medical License #* Email
ADDITIONAL SITES UPDATES MADE TO THIS SECTION
List additional practices/satellite programs. If the practices/satellite is already enrolled with VFC, please provide
the VFC Pin number. Practices/satellite sites may be enrolled by completing a separate enrollment package
for each (attach additional sheets if necessary).
Facility Name Zip Code Is this site VFC Enrolled If Yes, please provide PIN
Vaccines for Children Program
NYC DOHMH Bureau of Immunization
42-09 28
th
Street, 5
th
Floor, CN-21
Queens, New York, 11101-4132
Phone: (347) 396-2404 / Fax: (347) 396-2559
Rev 10/23/17 1
PROVIDER AGREEMENT
To receive publicly funded vaccines at no cost, I agree to the following conditions, on behalf of myself and all the
practitioners, nurses, and others associated with the health care facility of which I am the medical director or equivalent:
1.
I will annually submit a provider profile representing populations served by my practice/facility. I will submit more
frequently if 1) the number of children served changes or 2) the status of the facility changes during the calendar year.
2.
I will screen patients and document eligibility status at each immunization encounter for VFC eligibility (i.e., federally or
state vaccine-eligible) and administer VFC-purchased vaccine by such category only to children who are 18 years of age or
younger who meet one or more of the following categories:
A.
Federally Vaccine-eligible Children (VFC eligible)
1.
Are an American Indian or Alaska Native;
2.
Are enrolled in Medicaid;
3.
Have no health insurance;
4.
Are underinsured: A child who has health insurance, but the coverage does not include vaccines; a child whose
insurance covers only selected vaccines (VFC-eligible for non-covered vaccines only). Underinsured children are
eligible to receive VFC vaccine only through a Federally Qualified Health Center (FQHC), or Rural Health Clinic
(RHC) or under an approved deputization agreement.
B.
State Vaccine-eligible Children
1.
In addition, to the extent that my state designates additional categories of children as “state vaccine-eligible”, I
will screen for such eligibility as listed in the addendum to this agreement and will administer state-funded doses
(including 317 funded doses) to such children.
Children aged 0 through 18 years that do not meet one or more of the eligibility federal vaccine categories (VFC eligible),
are not eligible to receive VFC-purchased vaccine.
3.
For the vaccines identified and agreed upon in the provider profile, I will comply with immunization schedules, dosages,
and contraindications that are established by the Advisory Committee on Immunization Practices (ACIP) and included in
the VFC program unless:
a)
In the provider's medical judgment, and in accordance with accepted medical practice, the provider deems such
compliance to be medically inappropriate for the child;
b)
The particular requirements contradict state law, including laws pertaining to religious and other exemptions.
4.
I will maintain all records related to the VFC program for a minimum of three years and upon request make these records
available for review. VFC records include, but are not limited to, VFC screening and eligibility documentation, billing
records, medical records that verify receipt of vaccine, vaccine ordering records, and vaccine purchase and accountability
records.
5.
I will immunize eligible children with publicly supplied vaccine at no charge to the patient for the vaccine.
6.
I will not charge a vaccine administration fee to non-Medicaid federal vaccine eligible children that exceeds the
administration fee cap of $17.85 per vaccine dose. For Medicaid children, I will accept the reimbursement for immunization
administration set by the state Medicaid agency or the contracted Medicaid health plans.
7.
I will not deny administration of a publicly 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 the 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 vaccine management including:
a)
Ordering vaccine and maintaining appropriate vaccine inventories;
b)
Not storing vaccine in dormitory-style units at any time;
c)
Storing vaccine under proper storage conditions at all times. Refrigerator and freezer vaccine storage units and
temperature monitoring equipment and practices must meet NYC Bureau of Immunization storage and handling
requirements;
d)
Returning all spoiled/expired public vaccines to CDC’s centralized vaccine distributor within six months of
spoilage/expiration
Vaccines for Children Program
NYC DOHMH Bureau of Immunization
42-09 28
th
Street, 5
th
Floor, CN-21
Queens, New York, 11101-4132
Phone: (347) 396-2404 / Fax: (347) 396-2559
Rev 10/23/17 2
10.
I agree to operate within the VFC program in a manner intended to avoid fraud and abuse. Consistent with "fraud" and
"abuse" as defined in the Medicaid regulations at 42 CFR § 455.2, and for the purposes of the VFC Program:
Fraud: is an intentional deception or misrepresentation made by a person with the knowledge that the deception could
result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under
applicable federal or state law.
Abuse: provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an
unnecessary cost to the Medicaid program, (and/or including actions that result in an unnecessary cost to the
immunization program, a health insurance company, or a patient); or in reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that
result in unnecessary cost to the Medicaid program.
11.
I will participate in VFC program compliance site visits including unannounced visits, and other educational opportunities
associated with VFC program requirements.
12.
For providers with a signed deputization Memorandum of Understanding between a FQHC or RHC and the NYC Bureau
of Immunization to serve underinsured VFC-eligible children, I agree to:
a)
Include “underinsured” as a VFC eligibility category during the screening for VFC eligibility at every visit;
b)
Vaccinate “walk-in” VFC-eligible underinsured children; and
c)
Report required usage data
Note: “Walk-in” in this context refers to any underinsured child who presents requesting a vaccine; not just established patients. “Walk-in” does not
mean that a provider must serve underinsured patients without an appointment. If a provider’s office policy is for all patients to make an appointment
to receive immunizations then the policy would apply to underinsured patients as well.
13.
For pharmacies, urgent care, or school located vaccine clinics, I agree to:
a)
Vaccinate all “walk-in” VFC-eligible children and
b)
Will not refuse to vaccinate VFC-eligible children based on a parent’s inability to pay the administration fee.
Note: “Walk-in” refers to any VFC eligible child who presents requesting a vaccine; not just established patients. “Walk-in” does not mean that a
provider must serve VFC patients without an appointment. If a provider’s office policy is for all patients to make an appointment to receive
immunizations then the policy would apply to VFC patients as well.
14.
I agree to replace vaccine purchased with state and federal funds (VFC, 317) that are deemed non-viable due to provider
negligence on a dose-for-dose basis.
15.
I will comply with NYS Public Health Law 2168 and the NYC Health Code Section 11.11(d) for reporting to the Citywide
Immunization Registry (CIR) all doses of vaccines administered to children < 19 years of age regardless of insurance status
or VFC eligibility.
16.
I understand this facility or the NYC Bureau of Immunization may terminate this agreement at any time. If I choose to
terminate this agreement, I will properly return any unused federal vaccine as directed by NYC Bureau of Immunization.
By signing this form, I certify on behalf of myself and all immunization providers in this facility, I have read and agree
to the Vaccines for Children enrollment requirements listed above and understand I am accountable (and each listed
provider is individually accountable) for compliance with these requirements.
Medical Director or Equivalent Name (print):
Signature:
Date:
Name (print) Second individual as needed:
Signature:
Date:
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Completed 4 May 2022

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