IMM-25, Vaccine for Children Program, Provider Enrollment
|New Jersey Department of Health |PROVIDER ENROLLMENT |
|Vaccines for Children (NJVFC) Program | |
|PO Box 369 | |
|Trenton, NJ 08625-0369 | |
|Phone: (609) 826-4862 Fax: (609) 826-4867 | |
This form is to be completed for each provider site location and is to be signed by the lead physician for the practice.
|Site Medicaid ID Number (Mandatory) |PIN Number |New Provider? |
| | |Yes No |
|Site Name |NPI Number |
| | |
|Address |
| |
|Name of Contact Person(s) |
| |
|Telephone Number |Fax Number |
|( ) |( ) |
|Medical License Number of Lead Physician |Business Email Address (Mandatory) |
| | |
|Is your practice/clinic a Federally Qualified Health Center (FQHC) Yes |Is your practice/clinic a Rural Health Center (RHC)? Yes No |
|No | |
|In order to participate in the New Jersey Vaccines For Children (NJVFC) Program and/or to receive other federally procured vaccine provided to me at no cost, I,|
|on behalf of myself and any and all practitioners, nurses and others associated with this medical office, group practice, managed care organization, health |
|department, community/migrant/rural clinic, or other entity of which I am the physician-in-chief or equivalent, agree to the following: |
|1. I will screen patients and administer NJVFC Program-purchased vaccine |6. I will provide the most current Vaccine Information Statement (VIS) at every |
|only to a child ( ................
................
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