Vaccines For Children (Vfc) Program Provider Agreement And Profile Page 5
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6NEW 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
FACILITY TYPE (select facility type)
Private Facilities
Public Facilities
Private Hospital
STD/HIV
Public Health Department Clinic
Private Practice (solo/group/HMO)
Family Planning
FQHC/RHC (Community/Migrant/Rural)
Community Health Center
Juvenile Detention Center
Community Health Center
Correctional Facility
Pharmacy
Tribal/Indian Health Services Clinic
Birthing Hospital
Drug Treatment Facility
Other
School-Based Clinic
Migrant Health Facility
Teen Health Center
Refugee Health Facility
Teen Health Center
Adolescent Only Provider
Adolescent Only
College
Other
VACCINES OFFERED (select only one box)
All ACIP Recommended Vaccines
Offers Select Vaccines (This option is only available for facilities designated as Specialty Providers by the VFC Program)
A “Specialty Provider” is defined as a provider that only serves (1) a defined population due to the practice specialty (e.g. OB/GYN; STD clinic;
family planning) or (2) a specific age group within the general population of children ages 0-18. Local health departments and pediatricians are
not considered specialty providers. The VFC Program has the authority to designate VFC providers as specialty providers. At the discretion of the
VFC Program, enrolled providers such as pharmacies and mass vaccinators may offer only influenza vaccine.
Select Vaccines Offered by Specialty Provider
DTaP
Hepatitis A
Hepatitis B
HIB
HPV
Influenza
Meningococcal Conjugate
MMR
Pneumococcal Conjugate
Pneumococcal Polysaccharide
Polio
Rotavirus
TD
Tdap
Varicella
Other, specify:
DOH-3836 (5/14) page 5 of 6
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