Vaccines For Children (Vfc) Program Provider Agreement And Profile Page 4

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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

9. I will comply with the requirements for vaccine management including:

a) Ordering vaccine and maintaining appropriate vaccine inventories;

b) Not storing vaccine in dormitory-style units at any time;

c) Storing vaccine under proper storage conditions at all times. Refrigerator and freezer vaccine storage units and temperature monitoring equipment and

practices must meet New York State Department of Health storage and handling requirements;

d) Returning all spoiled/expired public vaccines to CDC’s centralized vaccine distributor within six months of spoilage/expiration

10. I agree to operate within the VFC program in a manner intended to avoid fraud and abuse. Consistent with “fraud” and “abuse” as defined in the

Medicaid regulations at 42 CFR § 455.2, and for the purposes of the VFC Program:

Fraud: is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some

unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Abuse: provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the

Medicaid program, (and/or including actions that result in an unnecessary cost to the immunization program, a health insurance company, or

a patient); or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health

care. It also includes recipient practices that result in unnecessary cost to the Medicaid program.

11. I will participate in VFC program compliance site visits including unannounced visits, and other educational opportunities associated with VFC

program requirements.

12. For pharmacies, urgent care, or school located vaccine clinics, I agree to:

A. Vaccinate all “walk-in” VFC-eligible children and

B. Will not refuse to vaccinate VFC-eligible children based on a parent’s inability to pay the administration fee.

Note: “Walk-in” refers to any VFC eligible child who presents requesting a vaccine; not just established patients. “Walk-in” does not mean that a provider

must serve VFC patients without an appointment. If a provider’s office policy is for all patients to make an appointment to receive immunizations then the

policy would apply to VFC patients as well.

13. I agree to replace vaccine purchased with state or federal funds (VFC, 317) that are deemed non-viable due to provider negligence on a

dose-for-dose basis.

14. I will report ALL doses administered according to patient’s VFC vaccine eligibility, within two weeks of administration, in the New York State

Immunization Information System (NYSIIS). Providers are required by Public Health Law to report all childhood immunizations to NYSIIS.

I will use the NYSIIS Ordering Module to submit vaccine orders.

I will report vaccine inventory in NYSIIS and ensure that inventory reported with each order reflects current doses administered as reported

in NYSIIS.

I will record twice daily temperatures in NYSIIS.

If my practice uses an Electronic Medical Record (EMR) system to report doses administered to NYSIIS, I will ensure that the EMR system

contains the necessary fields required by NYSIIS and can export a data file for submission that uploads all required fields appropriately

into NYSIIS.