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The Florida Department of Health works to protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.

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VFC Program Initial Enrollment Form

If you have questions or encounter problems completing either of these forms, contact the State VFC Program at 1-800-483-2543 or email FloridaVFC@FLHealth.gov.

 
CDC Training Requirements for VFC Providers
 

The VFC Provider Initial Enrollment form is available as a fillable PDF form.

Hard-copy fillable PDF Form Instructions:

  1. Complete and submit this form via fax or mail.
  2. To complete the PDF form; save the form to your local computer before beginning the form, type the correct information in each field. All required fields are outlined in red. Be sure all information is correct even in non-required fields, such as delivery hours, to ensure that your VFC Program PIN is properly updated and vaccine is delivered to the appropriate location. Note: The VFC Program is not responsible for vaccine that is wasted due to incorrect delivery address or hours.
  3. Save the completed form to your local computer. Print the form and have the medical director or equivalent sign where indicated.
  4. Fax the form to the VFC Program at 850-245-4734.
  5. The VFC Program will notify VFC Program providers where any required training certificates should be sent. At this time, please do not send them in with the submitted form.

Download Hard-copy PDF Provider Enrollment Form


Online Form Instructions:

  1. Complete and submit this form online. All fields marked with an asterisk are required.
  2. Once you have completed the form you will be able to review your form content online prior to submitting. You must then use buttons at bottom of preview page to either go "Back to Form" and make corrections if needed, or you may "Submit Form." Once you have submitted the form, you will receive a confirmation email with your completed form shown. Print and sign a copy for your records. (Some email providers filter messages based on content, subject line, or the sender's address and may put your email into the spam or junk mail folder. Please make sure FloridaVFC@FLHealth.gov is on your "approved sender" list or "whitelist" and/or in your "address book.")
  3. Once your application has been reviewed and approved, a representative will contact you to schedule an onsite visit to evaluate project details and requirements, and to verify your refrigerator storage unit. All providers must comply with Vaccine Storage Equipment Requirement prior to participating in the VFC Program.

Note: Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead contact these offices by phone or in writing.

 

I agree to the following requirements:

1) I have a certified, calibrated thermometer for each vaccine storage unit.

2) I have a stand-alone, two-door refrigerator/freezer or equivalent unit.

3) I will notify the VFC Program when the VFC Program Coordinator, who is responsible for vaccine management, changes.

 
Provider Profile Information


Vaccine Delivery Information Mailing Information














Doctor's Clinic Indian Tribes
Hospital Clinic School Clinic
County Health Department Community Health Center
FQHC (Federally Qualified Health Center) Juvenile Correctional Center
Birthing Hospital Other
 
Terms and Conditions

1The 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:
    1. American Indian or Alaskan Native
    2. Enrolled in Medicaid
    3. Has no health insurance
    4. Underinsured: Children who have commercial (private) health insurance but the coverage does not include vaccines, children whose insurance covers only selected vaccines (VFC Program-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. Underinsured children are eligible to receive VFC Program vaccine only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputization agreement.
  2. Comply with immunization schedule, dosage, and contraindications that are established by the ACIP and included in the VFC Program unless:
    1. In the provider’s medical judgment, and in accordance with accepted medical practice, the provider deems such compliance to be medically inappropriate.
    2. The particular requirements contradict state law, including those pertaining to religious and other exemptions.
  3. Maintain all records related to the VFC Program for a minimum of three (3) years and make these records available to public health officials, including the state or Department of Health and Human Services (DHHS) upon request.
  4. Immunize eligible children with VFC Program-supplied vaccine at no charge for the vaccine to the patient or parent.
  5. Not charge a vaccine administration fee to the non-Medicaid VFC Program-eligible children that exceed the administration fee cap of $24.01 per vaccine dose. For Medicaid VFC Program-eligible children, accept the reimbursement for immunization administration set by the state Medicaid agency or the contracted Medicaid health plans.
  6. 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.
  7. Distribute the current Vaccine Information Statements (VIS) each time a vaccine is administered and maintain records in accordance with the National Childhood Vaccine Injury Compensation Act (NCVIA) which includes reporting clinically significant adverse events to the Vaccine Adverse Event Reporting System (VAERS).
  8. Comply with the requirements for vaccine ordering, vaccine accountability, and vaccine management. Agree to operate within the VFC Program in a manner intended to avoid fraud and abuse. VFC Program providers may not store federally purchased vaccine in dormitory-style refrigerators at any time. Return all spoiled/expired public vaccines to CDC’s centralized vaccine distributor within six (6) months of spoilage/expiration. I assume responsibility for the proper handling and storage of VFC Program-provided vaccine after delivery to my facility and understand that I may have to replace wasted vaccine.
  9. Participate in VFC Program compliance site visits, storage and handling unannounced visits, and other educational opportunities associated with VFC Program requirements.
  10. Enroll in the Florida State Health Online Tracking System (SHOTS), the statewide immunization registry, in order to place vaccine orders. Participation in Florida SHOTS will facilitate direct ordering of vaccine by VFC Program providers in the future. If you do not have a Florida SHOTS account, complete an enrollment form online at www.flshots.com/flshots/enroll/applicantquestions.html. If you do not know if you have a Florida SHOTS account, contact the Florida SHOTS help desk at 1-877-888-7468.
  11. Participate in all training required by the VFC Program.
  12. The VFC Program or the provider 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 any unused VFC Program vaccine.

All providers must comply with Vaccine Storage Equipment Requirement prior to participating in the VFC Program. Providers are required to have certified, calibrated thermometers, and stand-alone, two-door refrigerator/freezer units.


Please confirm your agreement by typing "yes" in the following box: 

Note: Form will be sent to this email address upon submission.
 
Delivery Infomation Section

Please note: This section is very important. It provides necessary shipping information.

Indicate the days of the week and times between the hours of 8 a.m. and 5 p.m., your local time, you may receive vaccine deliveries. If your office is closed, please enter "closed" in the opening time and closing time fields for applicable day(s).
Days of the Week Open Time Closed Time
Please Note: It is the provider's responsibility to notify the VFC Program in advance if the office will be closed during the days and times which are normally open for business. You can reach a VFC Program representative at 1-800-483-2543, option 6.
 
VFC Program Eligibility Section
In a 12-month period, estimate the number of VFC Program children, by age and eligibility, which will be immunized at this location. (For example, 3 in the “< 1 year old” category, 4 in the “1–6 years old” category, and 2 in the “7–18 years old” category, total 9.) Note: Do not count a child in more than one category.
VFC Program Eligibility A
<1 Year
B
1–6 Years
C
7–18 Years
(A+B+C)
Total
Enrolled in Medicaid
Uninsured
American Indian/Alaskan Native
Underinsured/FQHC
(has health insurance but it does not cover immunizations)
Privately Insured
Total
To be VFC Program-eligible, underinsured children must be vaccinated through a FQHC, RHC, or under an approved deputization agreement. Children who have private health insurance are not eligible for VFC Program vaccines.
 
Account Management in Florida SHOTS Section
Do you already have a Florida SHOTS account?
 
Are there other sites enrolled in the VFC Program?
 
If Yes, list all VFC Program PINs already enrolled in your organization:
 
Vaccine Management in Florida SHOTS Section
List personnel who, in addition to the VFC Program Coordinator and the Back-Up VFC Program Coordinator, need permissions to manage and order your VFC Program vaccine in Florida SHOTS. Place an "x" for the requested permission. All personnel must have a Florida SHOTS User ID to access VFC Program functionality. System User IDs can only be created by your local organization administrator or the Florida SHOTS help desk. Contact the Florida SHOTS help desk at 1-877-888-7468 for further assistance.
Personnel Name Florida SHOTS System User ID (yes OR no?) Update Inventory (Apply Pending Receipts to Inventory) Can see Orders (View Only for Order Status) Can Update Orders (Create/Modify VFC Program Vaccine Order Requests)
 
Required Training Documentation Section
All provider personnel who manage VFC Program vaccine must document completion of the following online courses offered by the CDC at www.cdc.gov/vaccines/ed/youcalltheshots.htm. Each participant must submit the certificate of completion. Place an "x" to indicate course completion.
Title Personnel Name Vaccines for Children (VFC) Webinar Vaccine Storage and Handling Webinar
Medical Director or Equivalent (provider who is signing the application)*
VFC Program Coordinator*
Back-up VFC Program Coordinator*
 
Provider List Section
Use this form to list all health care providers at your facility licensed to administer vaccines. To include additional immunization providers, send a separate email to FloridaVFC@flhealth.gov with the all the required documentation.
Last Name, First, MI Medical License Number Medicaid Number National Provider ID (NPI) Title (MD, DO, PA, NP) Specialty (Peds, Family, Med, Other)