Get Key Clinic Staff Change Request Form - California Vaccines For ... - Eziz

This guide provides a clear and supportive approach to completing the Key Clinic Staff Change Request Form required by the California Vaccines For Children Program. Follow the steps outlined below to ensure accurate and efficient submission of your change request.

Follow the steps to complete the Key Clinic Staff Change Request Form.

1. Select the ‘Get Form’ button to access the Key Clinic Staff Change Request Form. This action will allow you to retrieve the form and open it in your editing tool of choice.
2. Begin filling out the practice information section. Provide the practice name, Provider Identification Number (PIN), address, county, city, ZIP code, phone number, and fax number. Ensure all details are accurate and up to date.
3. In the 'Key Practice Staff Change' section, indicate the roles that are changing by checking the appropriate boxes next to 'Provider of Record,' 'Vaccine Coordinator,' 'Backup Vaccine Coordinator,' and 'Provider of Record Designee.'
4. For each staff member listed, provide their name, title (including their credentials such as MD, DO, NP, or PA), their specialty or clinic title if applicable, National Provider ID, and Medical License number where required.
5. Fill in the contact information for each key staff member by providing their direct phone number, specialty, clinic title, and email address. Repeat this for all staff members listed in the previous step.
6. If there are any changes to the Provider of Record, include a signed copy of the VFC Provider Agreement and the Certification of Capacity to Store and Manage Vaccines.
7. Finally, be sure the Provider of Record signs and dates the form to authorize the changes being requested. This signature acknowledges their responsibility for the compliance of key practice staff with VFC Program requirements.
8. Once all sections are accurately completed, save your changes. Follow-up options include downloading, printing, or sharing the form as needed to ensure timely submission.

Complete the Key Clinic Staff Change Request Form online today to ensure your clinic remains compliant with the VFC Program.