Get Mnvfc Provider Agreement Form

Completing the MnVFC Provider Agreement Form online is an essential step for healthcare facilities seeking to participate in the Minnesota Vaccines for Children Program. This guide will provide you with a clear and supportive approach to filling out the required sections of the form accurately.

Follow the steps to fill out the MnVFC Provider Agreement Form online.

1. Press the ‘Get Form’ button to access the MnVFC Provider Agreement Form and have it ready for editing.
2. Begin by entering the facility information, including the facility name, VFC PIN, address, city, county, state, telephone, and ZIP code. If the shipping address differs from the facility address, fill in that information as well.
3. Provide details about the medical director or equivalent who will sign the agreement. Include their last name, first name, middle initial, title, specialty, license number, Medicaid or NPI number, and employer identification number (optional).
4. Fill in the vaccine coordinator details. Provide the primary vaccine coordinator's name, telephone, and email. Indicate whether they have completed the required annual MnVFC online training. Repeat this step for the backup vaccine coordinator.
5. List all licensed healthcare providers practicing at your facility who have prescribing authority. Fill in the provider name, title, license number, Medicaid or NPI number, and employer identification number (optional).
6. In the Provider Agreement section, review and agree to the outlined conditions regarding vaccine administration and responsibilities, ensuring that all relevant agreements are acknowledged.
7. After completing all sections, ensure all information is accurate. Save the changes, and once you are ready, download, print, or share the form as required.

Complete your MnVFC Provider Agreement Form online today to ensure your facility is prepared for participation in the program.