Get De Dhss Practice Registration /delvax Facility Code Request Form

Filling out the DE DHSS Practice Registration /DelVAX Facility Code Request Form is an essential process for facilities that administer immunizations and wish to report them electronically. This guide will provide you with clear and user-friendly instructions to complete the form online accurately.

Follow the steps to effectively complete the form.

1. Click the ‘Get Form’ button to obtain the DE DHSS Practice Registration /DelVAX Facility Code Request Form and open it in the online editor.
2. Indicate your registration purpose by selecting one of the options: 'Registering Practice for Immunization reporting' or 'Requesting a Facility Code for Electronic Reporting'. Ensure you check the appropriate box.
3. Answer the question about ownership by selecting 'Yes' or 'No'. If applicable, provide the name of your organization.
4. If your facility participates in the Vaccines for Children Program, select 'Yes' and enter your VFC PIN, if available. If not, select 'No'.
5. Fill out the Group/Practice Information section by providing the group or practice name, address, phone number, email address, fax number, city, state, and ZIP code.
6. Provide the contact details for the individual responsible for managing this form, including their name and phone number.
7. If the office information differs from the group information, fill out the Facility Information section with the facility name, address, phone, email, fax, city, state, and ZIP code.
8. List the immunization ordering providers (such as physicians or nurse practitioners) who will be administering immunizations. Include their name and NPI number. You can add additional pages if necessary.
9. Similarly, fill out the details for each immunization administering provider. Again, include their name and NPI number. Ensure all relevant providers are listed.
10. After you have completed all the sections of the form, review it for accuracy. Once satisfied, you can save your changes, download a copy, print it, or share it as needed.

Complete your DE DHSS Practice Registration /DelVAX Facility Code Request Form online today.