Get Changes To Enrollment Form

Filling out the Changes To Enrollment Form online is a straightforward process that allows users to efficiently communicate any alterations regarding their facility's enrollment in the Texas Vaccines for Children (TVFC) and Adult Safety Net (ASN) programs. This guide provides clear instructions for each section of the form to ensure that users can complete it accurately and confidently.

Follow the steps to complete the Changes To Enrollment Form online.

1. Click the ‘Get Form’ button to obtain the Changes To Enrollment Form and open it in an online editor.
2. Begin with Section A, where you will enter the original facility information. Make sure to provide the PIN, today's date, original facility name, vaccine delivery address, city, county, and zip code.
3. In Section B, if you are changing your facility name, enter the new facility name. Ensure that the name adheres to the specified guidelines, including character limitations and punctuation restrictions.
4. For Section C, provide the details of the new signing clinician, including their name, title, specialty, email address, medical license number, and Medicaid or NPI number.
5. In Section D, indicate any changes in prescribing authorities by adding or removing names. List each individual's title, medical license number, and Medicaid or NPI number as necessary.
6. Fill out Section E, which requires data on patient population changes. Report the number of patients who have received vaccines categorized by age group and insurance status for both children and adults.
7. Choose the type of data you are using to determine the provider population in Section F. This could include various data sources like Medicaid claims or immunization information systems.
8. Complete the TVFC/ASN program agreement in Section F by reviewing the statements and having the signing clinician provide their signature and date.
9. Finally, review all the information you've entered for accuracy, then save changes. You can download, print, or share the Changes To Enrollment Form based on your needs.

Complete your Changes To Enrollment Form online today to ensure your facility's enrollment is accurate and up-to-date.