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How to fill out the Doh 3836 Form online
The Doh 3836 Form is essential for registering healthcare providers in New York State's Vaccines for Children program. This guide provides clear instructions on how to fill out the form online, ensuring you accurately complete each section while meeting all requirements.
Follow the steps to fill out the Doh 3836 Form online effectively.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering your primary provider information, which includes the last name, first name, middle name, medical license number, Medicaid number, title (e.g., MD, NP), specialty, and email address. Ensure all fields are accurately filled out.
- Proceed to the facility/practice section. Fill in the facility name, PFI number (if applicable), street address, PO Box (if applicable), city, county, state, phone number, fax number, shipping contact name, shipping contact email address, and zip code.
- In the office hours section, input your practice's operating hours for each weekday, noting any lunch closures. Use the appropriate AM/PM designation for all entries.
- Specify your practice type by checking the appropriate box that describes your healthcare facility (e.g., community health center, pharmacy).
- Complete the annual patient numbers section by providing the projected number of children in different age categories who will receive vaccinations over the next twelve months. Ensure you specify how you determined these numbers.
- Review and agree to the health care provider agreement, acknowledging your commitment to the program's requirements. Ensure your signature, along with the VFC PIN number (if applicable), is correctly entered.
- List all authorized practitioners working at your facility, including their last name, first name, middle name, medical license number, title, and Medicaid/NPI number. Ensure all additional providers are included.
- Once all sections are complete, review the form for accuracy. After confirming all information is correct, save your changes. You may then download, print, or share the completed form as required.
Complete your Doh 3836 Form online today to ensure your practice is registered for the Vaccines for Children program.
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