Get Nevada Division Of Public And Behavioral Health - State Of Nevada - Vfcnevada

Filling out the Nevada Division of Public and Behavioral Health VFC Program agreement can be a crucial step for healthcare providers participating in the Vaccines for Children Program. This guide provides clear, step-by-step instructions to help you complete the online form effectively.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the online document and open it for editing.
2. Begin by entering the facility information. Fill out the facility name, address, city, county, state, phone number, and mailing address if it differs from the shipping address.
3. In the Medical Director or Equivalent section, provide the last name, first name, middle initial, title, specialty, license number, Medicaid or NPI number, and optionally the employer identification number.
4. List the Primary Vaccine Coordinator’s name, telephone number, email address, and indicate if the annual training is completed. Then provide the same information for a Back-Up Vaccine Coordinator.
5. Under the Providers Practicing at This Facility section, list all licensed healthcare providers at your facility who have prescribing authority, including their name, title, license number, Medicaid number, and NPI number if applicable.
6. Read and confirm your agreement to the provider agreement terms, ensuring to check each safety and compliance measure as agreed upon.
7. Complete the vaccination shipping hours section, indicating the days and times your clinic is open to receive vaccine deliveries.
8. Fill out the Nevada State Immunization Program Provider Profile Form with the required details such as provider's name, facility name, vaccine delivery address, and select facility type.
9. Provide the number of children vaccinated by age category in both VFC and non-VFC Vaccine Eligibility Categories per the guidelines outlined in the form.
10. Finally, review all entered information for accuracy. Once satisfied, save your changes, download, print, or share the completed form as needed.

Complete your document online today for a seamless filing experience.