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VFC Program Provider Profile/Update Form

Contact the Immunization Section

All health care providers participating in the Vaccines for Children (VFC) program must complete this form annually or more frequently if the number of children served changes or the status of the facility changes during the calendar year. All fields marked with an asterisk (*) are required.
 
Please check which type of form this is for your PIN:
 
 
 
FACILITY INFORMATION

(form submission will be sent to this email)
 
FACILITY TYPE (select facility type)
Private FacilitiesPublic Facilities
Private Hospital
Private Practice (solo/group/HMO)
Private Practice (solo/groups as agent for FQHC/RHC-deputized)
Community Health Center
Pharmacy
Birthing Hospital
School-Based Clinic
Teen Health Center
Adolescent Only Provider
Other:
Public Health Department Clinic
Public Health Department Clinic as agent for FQHC/RHC-deputized
Public Hospital
FQHC/RHC (Community/Migrant/Rural)
Community Health Center
Tribal/Indian Health Services Clinic
Woman Infants and Children
Other:
STD/HIV
Family Planning
Juvenile Detention Center
Correctional Facility
Drug Treatment Facility
Migrant Health Facility
Refugee Health Facility
School-Based Clinic
Teen Health Center
Adolescent Only
 
DELIVERY INFORMATION SECTION
Indicate the days of the week and times between the hours of 8 a.m. and 5 p.m., your local time, you will receive vaccine deliveries.
Day of the WeekOpen TimeClosed 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.
 
VACCINE INVENTORY MANAGEMENT within FLORIDA SHOTS
Personnel who, in addition to the VFC Vaccine Coordinator and the Back-Up VFC Vaccine Coordinator, need VFC inventory permissions added or removed from their Florida SHOTS User ID 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.
AddRemovePersonnel NameFlorida 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)
 
VACCINES OFFERED
 
 
A “Specialty Provider” is defined as a provider that only serves (1) a defined population due to the practice specialty (e.g. OB/GYN; STD clinic; family planning) or (2) a specific age group within the general population of children ages 0-18. Local health departments and pediatricians are not considered specialty providers. The VFC Program has the authority to designate VFC providers as specialty providers. At the discretion of the VFC Program, enrolled providers such as pharmacies and mass vaccinators may offer only influenza vaccine.
 
Select Vaccines Offered by Specialty Provider:













 
PROVIDER POPULATION
Provider Population based on patients seen during the previous 12 months. Report the number of children who received vaccinations at your facility, by age group. Only count a child once based on the status at the last immunization visit, regardless of the number of visits made. The following table documents how many children received VFC vaccine, by category, and how many received non-VFC vaccine.
VFC Vaccine Eligibility Categories# of children who received VFC Vaccine by Age Category
A
<1 Year
B
1–6 Years
C
7–18 Years
(A+B+C)
Total
Enrolled in Medicaid
No Health Insurance
American Indian/Alaskan Native
Underinsured in FQHC/RHC or deputized facility1
Total VFC:
Non-VFC Vaccine Eligibility Categories# of children who received VFC Vaccine by Age Category
A
<1 Year
B
1–6 Years
C
7–18 Years
(A+B+C)
Total
Insured (private pay/health insurance covers vaccines)
Children's Health Insurance Program (CHIP)2
Total Non-VFC:
Total Patients: (must equal sum of Total VFC + Total Non-VFC):

1Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that are not covered by insurance.

In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputized provider. The deputized provider must have a written agreement with an FQHC/RHC and the state/local/territorial immunization program in order to vaccinate these underinsured children.

2CHIP – Children enrolled in the state Children’s Health Insurance Program (CHIP). These children are considered insured and are not eligible for vaccines through the VFC program. Each state provides specific guidance on how CHIP vaccine is purchased and administered through participating providers.

 
TYPE OF DATA USED TO DETERMINE PROVIDER POPULATION (choose all that apply)