Add/delete Individual Provider(S) In Delvax - Delaware Immunization Program
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1DELAWARE IMMUNIZATION PROGRAM
Add/Delete Individual Provider(s) in DelVAX
USE THIS FORM TO ADD OR REMOVE INDIVIDUAL PROVIDERS (PHYSICIANS AND NURSE PRACTIONERS) FROM YOUR DELVAX
PROVIDER/CLINIC ACCOUNT
Please Print
Please Print
GROUP/PRACTICE INFORMATION
Group/Practice Name:
Address:
Phone:
E-mail:
Fax:
City:
State:
ZIP Code:
Contact Name/Phone
IT Contact Name/Phone
NPI:
Taxonomy
EIN
ADD INDIVIDUAL PROVIDER
INDIVIDUAL PROVIDERS (ONLY PHYSICIANS AND NURSE PRACTITIONERS WHO ADMINISTER VACCINE)
(Use Additional Pages if Necessary)
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
DELETE INDIVIDUAL PROVIDER
INDIVIDUAL PROVIDERS (ONLY PHYSICIANS AND NURSE PRACTITIONERS WHO ADMINISTER VACCINE)
(Use Additional Pages if Necessary)
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
Name:
NPI:
Effective Date
Physician
Nurse Practitioner
Fax completed form to 1-302-739-6627
For questions call 800-282-8672
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