Provider Reenrollment Form

The VFC Provider Initial Enrollment form is now available in fillable PDF form format:

Download Hard-copy PDF Provider Reenrollment Form

1. Complete and submit this form. If you have questions or encounter problems completing this form, contact the State VFC Program at 800-483-2543 or email FloridaVFC@flhealth.gov.
2. To complete the form; save the form to your local computer, 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. After you have completed the form be sure to save the 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.

If you have questions or encounter problems completing this form, contact the Florida Vaccines for Children Program at 800-483-2543.

*Note: This page contains materials in the Portable Document Format (PDF).  The free Adobe Reader may be required to view these files.