Vaccines For Children (Vfc) Program Provider Agreement And Profile Page 3

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NEW YORK STATE DEPARTMENT OF HEALTH

FOR DOH USE ONLY Date rec’d:

Bureau of Immunization

Vaccine Program

VFC PIN #

ESP Corning Tower RM 649

Albany NY 12237–0627

Phone: (800) 543-7468 Fax: (518) 449-6912

PROVIDER AGREEMENT

To receive publicly funded vaccines at no cost, I agree to the following conditions, on behalf of myself and all the practitioners, nurses, and others

associated with the health care facility of which I am the medical director or equivalent:

1. I will annually submit a provider profile representing populations served by my practice/facility. I will submit more frequently if 1) the number

of children served changes or 2) the status of the facility changes during the calendar year.

2. I will screen patients and document eligibility status at each immunization encounter for VFC eligibility (i.e., federally or state vaccine-eligible)

and administer VFC-purchased vaccine by such category only to children who are 18 years of age or younger who meet one or more of the

following categories:

A. Federally Vaccine-eligible Children (VFC eligible)

1) Are an American Indian or Alaska Native;

2) Are enrolled in Medicaid;

3) Have no health insurance;

4) Are underinsured: A child who has health insurance, but the coverage does not include vaccines; a child whose insurance covers only selected vaccines

(VFC-eligible for non-covered vaccines only). Underinsured children are eligible to receive VFC vaccine only through a Federally Qualified Health Center

(FQHC), or Rural Health Clinic (RHC) or under an approved deputization agreement.

B. State Vaccine-eligible Children

1) In addition, to the extent that my state designates additional categories of children as “state vaccine-eligible”,

I will screen for such eligibility as listed in the addendum to this agreement and will administer state-funded doses (including 317 funded doses) to such

children.

Children aged 0 through 18 years that do not meet one or more of the eligibility federal vaccine categories (VFC eligible), are not eligible to

receive VFC-purchased vaccine.

3. For the vaccines identified and agreed upon in the provider profile, I will comply with immunization schedules, dosages, and contraindications

that are established by the Advisory Committee on Immunization Practices (ACIP) and included in the VFC program unless:

A. In the provider’s medical judgment, and in accordance with accepted medical practice, the provider deems such compliance to be medically inappropriate for

the child;

B. The particular requirements contradict state law, including laws pertaining to religious and other exemptions.

4. I will maintain all records related to the VFC program for a minimum of three years and upon request make these records available for review. VFC records

include, but are not limited to, VFC screening and eligibility documentation, billing records, medical records that verify receipt of vaccine, vaccine ordering

records, and vaccine purchase and accountability records.

5. I will immunize eligible children with publicly supplied vaccine at no charge to the patient for the vaccine.

6. VFC Vaccine Eligible Children

I will not charge a vaccine administration fee to non-Medicaid federal vaccine eligible children that exceeds the administration fee cap of $25.10

per vaccine dose. For Medicaid children, I will accept the reimbursement for immunization administration set by the state Medicaid agency or

the contracted Medicaid health plans.

Non-VFC Vaccine Eligible Children

I will not charge a vaccine administration fee to non-Medicaid state vaccine-eligible children that exceeds the administration fee cap of $25.10

per vaccine dose. I will accept the reimbursement for immunization administration set by the State Children’s Health Insurance Program

(SCHIP).

7. I will not deny administration of a publicly purchased vaccine to an established patient because the child’s parent/guardian/individual of record

is unable to pay the administration fee.