Get Vfc Provider Information - Scdhec

This guide provides clear and concise instructions for filling out the VFC PROVIDER INFORMATION form required by the South Carolina Department of Health and Environmental Control (DHEC). Proper completion of this form ensures your information is accurately recorded for vaccine delivery and provider agreements.

Follow the steps to complete your VFC provider information form

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. In section A, enter your IRS business tax identification number and today's date in the specified fields.
3. Proceed to section B and provide your facility name or your first and last name along with your middle initial if applicable.
4. In section C, complete the shipping contact information thoroughly. Include the last name, first name, middle initial, vaccine delivery address (ensure no P.O. Boxes), city, state, zip code, and county. Additionally, provide the required telephone number, fax number, and email address.
5. If there is a mailing contact different from the shipping contact, fill out section C2 with the necessary details, similar to the shipping contact information.
6. In section D, indicate any days of the week and hours when you are not available to receive vaccines.
7. In section E, select one option from the type of facility provided. Options include private practice, private hospital, federally qualified health center or rural health clinic, other public facility, or other private facility.
8. List all physicians and practitioners who will be administering VFC vaccines in your practice. Ensure to include their names, medical license numbers or advanced practice numbers, and National Provider Identifiers (NPI). If needed, add additional pages for more practitioners.
9. After completing the form, review your entries for accuracy. Save your changes, and proceed to download, print, or share the form as required. Finally, mail or fax the completed form to DHEC, Immunization Division at the provided address or fax number.

Start completing your VFC PROVIDER INFORMATION form online today for accurate and timely processing.