Get Tvfc Provider Enrollment Form (e6-102)

The TVFC Provider Enrollment Form (E6-102) is essential for healthcare providers seeking to participate in the Vaccines for Children program. This guide will help you navigate the online process of filling out this form, ensuring you understand each section and the information required.

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

1. Click the ‘Get Form’ button to obtain the TVFC Provider Enrollment Form and open it for editing.
2. Begin by filling out the facility information, including the facility name, VFC PIN, address, city, county, state, telephone number, and ZIP code. If your shipping address differs from your facility address, provide that information here as well.
3. In the medical director or equivalent section, enter the personal details of the practitioner who is authorized to administer pediatric vaccines. This includes their last name, first name, middle initial, title, specialty, license number, Medicaid number, and optionally, the employer identification number.
4. Designate a primary vaccine coordinator by filling in their name, telephone number, and email address. Confirm whether they have completed the annual training by selecting 'Yes' or 'No'. If applicable, provide information for a back-up vaccine coordinator, including their name, type of training received, contact details, and training completion status.
5. List all healthcare providers practicing at the facility who have prescribing authority. For each provider, include their name, title, license number, Medicaid or EIN, and NPI number if applicable. If more space is needed, attach additional pages as necessary.
6. Review the provider agreement portion of the form. Ensure that you understand and agree to the conditions outlined, including compliance with immunization schedules and proper record-keeping.
7. After completing all required sections accurately, review the form for any errors or omissions. Once satisfied, you can save your changes, download a copy for your records, print it, or share it as necessary.

Complete the TVFC Provider Enrollment Form online to ensure your facility participates in the Vaccines for Children program.