Get Alaska Vaccine Distribution Program Enrollment ... - Epidemiology - Epi Alaska

This guide provides comprehensive instructions on completing the Alaska Vaccine Distribution Program Enrollment form. Whether you are enrolling for the first time or updating your registration, these steps aim to streamline the process and ensure accuracy.

Follow the steps to successfully complete the enrollment form.

1. Press the 'Get Form' button to access the necessary enrollment form and open it in the editing interface.
2. Indicate whether this is your first registration or a renewal of an existing registration. If it’s a first-time enrollment, ensure to attach a log documenting two weeks of temperatures from your main storage refrigerator/freezer.
3. In Section 1, provide the contact details of the person who will receive the vaccine shipments, including a physical delivery address (P.O. Boxes are not permitted), as well as a phone number, fax number, and email address. Mention any specific delivery instructions if necessary.
4. In Section 2, if your mailing information differs from the shipping details, list the name and contact details of the person responsible for receiving any mail related to the Alaska Vaccine Distribution Program.
5. Complete Section 3 by marking the type of facility you represent (public or private) and indicating whether it is classified as a Federally Qualified Health Center.
6. In Section 4, provide an estimate of the number of patients who will receive vaccinations at your facility, categorized by age group within a 12-month period.
7. For Section 5, indicate if your facility supplies Yellow Fever vaccine, and provide the name and stamp number of the certified Yellow Fever provider.
8. Section 6 requires the certifying physician or advanced nurse practitioner to review the terms of the Alaska Immunization Program contract and provide their name, Medicaid number, Medical License number, date, and signature.
9. In Section 7, list all additional practitioners at your facility who will administer vaccines, including their Medicaid and Medical License numbers. If a Medicaid number is pending, indicate 'pending' and reach out as soon as it is issued.
10. Section 8 allows you to fill in an emergency plan template or develop one of your own, which must be submitted along with your certification.
11. Once you've completed all sections, ensure to save changes to the form. You can then download, print, or share the document as needed.

Start completing your documents online to facilitate your enrollment in the Alaska Vaccine Distribution Program.