Get Wi Dhs F-02495 2019-2025

The Wisconsin Department of Health Services F-02495 form is a Provider Agreement for the Vaccine for Adults (VFA) program. This guide provides detailed instructions on how to complete the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the document and open it for completion.
2. Begin by filling out the Facility Information section, including the facility name, street address, city, county, telephone number, state, and zip code. If the mailing address is different from the street address, include that information as well.
3. In the Medical Director or Authorized Designee Information section, provide the name, license number, title, and either Medicaid or NPI number of the medical director. If there is an authorized designee, include their name, license number, and relevant details.
4. Complete the VFA Vaccine Coordinator Information by providing the names, telephone numbers, and email addresses of both the primary and backup vaccine coordinators.
5. In the Provider Agreement section, read through the outlined responsibilities and ensure you understand each requirement. You may want to take notes on the compliance conditions.
6. Confirm that you agree to operate within the VFA program guidelines and specific conditions included in the agreement by signing the appropriate signature fields and dating the document.
7. Once all sections are completely filled out, review the form for any errors or omissions to ensure accuracy.
8. At the end of the form, you will have the option to save your changes, download the document for your records, print a hard copy, or share the completed form as necessary.

Complete the WI DHS F-02495 form online today to participate in the VFA program.