If you have questions or encounter problems completing either of these forms, contact the State VFC Program at 1-800-483-2543 or email
Hard-Copy Provider Agreement Form
*Note: This page contains materials in the Portable Document Format (PDF). The free Adobe Reader may be required to view these files.
The VFC Program Reenrollment form is available as a fillable PDF form.
Hard-copy fillable PDF Form Instructions:
Complete and submit this form via fax or mail.
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. Save the completed form to your local computer. Print the form and have the medical director or equivalent sign where indicated.
Fax the form to the VFC Program at 850-245-4734.
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 Agreement Form
Online Form Instructions:
Complete and submit this form online. All fields marked with an asterisk are required.
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.")
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.
*Please confirm your agreement to these requirements by typing "yes" in the following box:
Provider Profile Information
Name of physician's office, practice, or clinic:*
Assigned VFC PIN:*
Vaccine Delivery Information
Vaccine Delivery Address:* (Number/Street–No PO Boxes)
Mailing address: (if different from shipping information)
VFC Program Coordinator:* 1
Back-Up VFC Program Coordinator:* 1
Choose the one provider category below that best describes you:*
Terms and Conditions
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. 1
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:
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:
American Indian or Alaskan Native
Enrolled in Medicaid
Has no health insurance
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.
Comply with immunization schedule, dosage, and contraindications that are established by the ACIP and included in the VFC Program unless:
In the provider’s medical judgment, and in accordance with accepted medical practice, the provider deems such compliance to be medically inappropriate.
The particular requirements contradict state law, including those pertaining to religious and other exemptions.
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.
Immunize eligible children with VFC Program-supplied vaccine at no charge for the vaccine to the patient or parent.
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.
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.
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).
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.
Participate in VFC Program compliance site visits, storage and handling unannounced visits, and other educational opportunities associated with VFC Program requirements.
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. Participate in all training required by the VFC Program.
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.
Yes, I have read and agree to the terms and conditions above.*
Please confirm your agreement by typing "yes" in the following box:
Signature:* Name of Medical Director or equivalent (MD, DO, or PA, NP)
Applicant Email:* Note: Form will be sent to this email address upon submission.
Medical License number:*
VFC Program Eligibility Section
In a 12-month period,
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. report
VFC Program Eligibility
Enrolled in Medicaid
American Indian/Alaskan Native
(has health insurance but it does not cover immunizations)
Privately Insured ‡
†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.
Please provide any questions or comments in the box below:
Enter Confirmation Number: