State of Florida Immunization Section Florida Department of Health Florida Vaccines for Children (VFC) Program 2014 Provider Reenrollment Form

The Complete the Provider Reenrollment form is acquired either electronically through the Florida Health Department’s website http://www.floridahealth.gov/prevention-safety or by fax or mail. The mentioned agreement must be completed with the Vaccines for Children Program’s conditions.

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01/2014 
 
1   of  5  State of Florida 
– Immunization Section                                                           Florida Department of Health   
 
Florida Vaccines for Children (VFC) Program 
2014 Provider Reenrollment Form 
 
Instructions:  The Provider Reenrollment Form is the provider’s agreement to comply with all the conditions of the VFC Program.  
Providers must complete this form annually. 
 
1.   Complete this form. You may also submit this form electronically via our website at  http://www.floridahealth.gov/prevention-safety-
and-wellness/immunization/vaccines-for-children/reenrollment.html .  
2.
  Fax or mail your application to: 
    Florida Vaccines for Children (VFC) Program  4052 Bald Cypress Way, Bin A-11, Tallahassee, FL  32399- 1700 
Fax:  850- 245-4734   
3.     All providers must comply with Vaccine Storage  Equipment Requirement prior to participating in the VFC Program . Please indicate 
your agreement with the following requirement s: 
 
_______   I:  
   have a certified, calibrated thermometer for each vaccine storage unit. 
   have a stand-alone, two-door refrigerator/freezer or equivalent unit. 
   will notify the VFC Program when the VFC Program Coordinator, who is responsible for vaccine management, 
changes. 
 
  Provider Profile Section  
N AME OF PHYSICIAN’S OFFICE,   PRACTICE, OR CLINIC  
 
  ASSIGNED VFC PIN  
Vaccine Delivery  Information   ( All Fields  Required)   Mailing Information  
VACCINE DELIVERY ADDRESS (Number/Street   -   No P.O. Boxes )  
 
  MAILING ADDRESS ( if different from shipping information )  
 
CITY                                                                          ZIP CODE  
  CITY                                                                        ZIP CODE  
 
TELEPHONE NUMBER  
 
  FAX  NUMBER  
VFC  Program  Coordinator * :   EMAIL ADDRESS  
Back - Up VFC  Program  Coordinator * :   EMAIL ADDRESS  
 
Check the one provider category that best describes you:  
 
 Doctor’s Clinic  
 Hospital Clinic  
 County Health Department  
 FQHC (Federally Qualified Health Center)  
 Birthing Hospital    Indian Tribes  
 School Clinic  
 Community Health Center  
 Juvenile Correctional Center  
 Other (specify):    
 
*The VFC Program Coordinator and the Back-Up VFC Program Coordinator will be assigned ordering and inventory permissions for this 
VFC Program PIN within the Florida SHOTS account. 
 
In order to participate in the Vaccines for Children (VFC) Program and/or to receive other publicly funded vaccine provided  
to me at no cost, I, on behalf of myself and all practitioners associated with this medical office, group practice, health maintenance  
organization, health department, community/rural clinic, or other entity of which I am the medical director or equivalent, agree  
to the following conditions: 
 
1.  Screen patients and document eligibility status at all immunization encounters for eligibility and administer VFC 
Program-purchased vaccine only to children who are 18 years of age or younger, and meet one or more of the following 
categories:  
a.  American Indian or Alaskan Native 
b.   Enrolled in Medicaid 
c.   Has no health insurance