Get Vaccine Transfer Form - Ct.gov - Ct

This guide provides clear and concise instructions for filling out the Vaccine Transfer Form. Properly completing this form is essential for the legitimate and safe transfer of vaccines between providers.

Follow the steps to accurately complete the Vaccine Transfer Form.

1. Press the ‘Get Form’ button to access the Vaccine Transfer Form. This will allow you to open the document in your preferred online editor.
2. Begin by filling out the 'Transferring Provider' section. Enter the name of the transferring facility, provider PIN number, date, address, phone number, and the name of the person completing the form.
3. Indicate your intent to transfer the vaccine by checking off any required confirmations, ensuring you are maintaining compliance with the specified instructions.
4. Complete the 'Receiving Transferred Vaccine' section. This includes entering details such as the receiving provider's facility name, provider PIN number, address, and phone number.
5. List the vaccine details including NDC number, lot number, number of doses transferred, and expiration date in the designated fields.
6. Ensure that both the transferring and receiving providers sign and date the form at the bottom to validate the transfer.
7. After thoroughly completing the form, save your changes. You may download, print, or share the form by using the available options in your online editor.
8. Fax the completed form to the Connecticut Vaccine Program at (860) 509-8371 or email it to DPH.IMMUNIZATIONS@ct.gov. Retain a copy for your records.

Get started with filling out the Vaccine Transfer Form online today.