Get Minnesota Vaccines For Children Mnvfc Program Provider Agreement - Minnesota Dept Of Health Mnvfc

Filling out the Minnesota Vaccines For Children Program Provider Agreement is essential for health care providers participating in the MnVFC program. This guide is designed to assist users in completing the agreement accurately and efficiently in an online format.

Follow the steps to complete the agreement online.

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. Begin by entering the site information, including the site name, MnVFC PIN, address, city, county, telephone number, state, and ZIP code.
3. Provide the medical director's or equivalent individual's information, including their last name, first name and middle initial, title, specialty, license number, and either Medicaid or NPI number.
4. Indicate whether the immunization manager and vaccine coordinator have completed the required annual MnVFC online training by selecting 'Yes' or 'No' in the respective options.
5. List all additional licensed health care providers who have prescribing authority in your practice on the last page of the agreement.
6. Review and agree to the provider agreement terms outlined in the form, ensuring that you understand each condition and requirement for participating in the program.
7. Once all information is filled in and verified, sign the provider agreement and include the date of signing.
8. Return the completed agreement by emailing it to health.mnvfc@state.mn.us or mailing it to the provided address.

Complete your MnVFC Program Provider Agreement online now to ensure your participation.