Get Provider Enrollment Form - Tennessee Web Immunization System

This guide will provide you with clear and professional instructions on completing the Provider Enrollment Form for the Tennessee Web Immunization System online. By following these steps, you can ensure that your enrollment process is efficient and accurate.

Follow the steps to successfully complete the Provider Enrollment Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Carefully read the introduction and instructions provided on the form to understand the requirements for enrollment.
3. In the first section, select whether you are a new provider or a reenrolling provider by checking the appropriate box.
4. Proceed to fill out the practice information section, including the name, VFC PIN number, and mailing address of your facility. Make sure to include the city, county, state, and ZIP code for accuracy.
5. For vaccine delivery, indicate the shipping address separately, ensuring it is not a P.O. Box. Provide the primary VFC contact's name, a second contact's name, and their email addresses, which are required fields.
6. Define whether you are a private provider, a TennCare provider, or a public health department site by checking the relevant boxes.
7. Select the provider type by checking only one category from the list provided, ensuring to follow any additional instructions if your facility falls under FQHC or RHC categories.
8. Indicate the type and number of vaccine storage units you have. This includes different categories for refrigerators and freezers specifically designed for vaccine storage.
9. Report the number of active patients served by your facility over a 12-month period, differentiating by age groups: under 1 year, 1 through 6 years, and 7 through 18 years.
10. Detail the number of children who were VFC-eligible based on specific eligibility categories. Remember not to double count any child across categories.
11. Complete the provider agreement section by reading the terms and confirming your understanding. Provide the required signatures and details including the print name of the chief physician and their medical license number.
12. List all healthcare providers with prescription writing privileges at your site, providing necessary details for each provider.
13. Type in the email address designated for all VFC communications to ensure you receive updates from the program.
14. Review the completed form for any errors or omissions before saving your changes.
15. Upon final review, download, print, or share the form as required. Ensure the signed copy is mailed to the specified address for the TN VFC Program.

Complete your Provider Enrollment Form online today to ensure timely participation in the VFC Program.