Approver Comments:
Status:
PENDING PROVIDER SUBMISSION
VFC PIN:
Organization Name:
Facility Name:
Agreement Signatory:
Agreement Signatory Title:
Is Information Sharing Agreement current?
Yes
No
Last Renewed:
--select--
2024
2023
2022
Facility Address:
Street Address:
Street Address2:
City:
State:
--select--
U.S. Armed Forces - Americas
U.S. Armed Forces - Europe
U.S. Armed Forces - Pacific
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
County:
--select--
APACHE
COCHISE
COCONINO
GILA
GRAHAM
GREENLEE
LA PAZ
MARICOPA
MOHAVE
NAVAJO
PIMA
PINAL
SANTA CRUZ
YAVAPAI
YUMA
Zip Code:
Vaccine Delivery Address:
Check if vaccine delivery address is the same as facility address:
Street Address:
Street Address2:
City:
State:
--select--
U.S. Armed Forces - Americas
U.S. Armed Forces - Europe
U.S. Armed Forces - Pacific
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
County:
--select--
APACHE
COCHISE
COCONINO
GILA
GRAHAM
GREENLEE
LA PAZ
MARICOPA
MOHAVE
NAVAJO
PIMA
PINAL
SANTA CRUZ
YAVAPAI
YUMA
Zip Code:
Mailing Address:
Check if mailing address is the same as facility address:
Street Address:
Street Address2:
City:
State:
--select--
U.S. Armed Forces - Americas
U.S. Armed Forces - Europe
U.S. Armed Forces - Pacific
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
County:
--select--
APACHE
COCHISE
COCONINO
GILA
GRAHAM
GREENLEE
LA PAZ
MARICOPA
MOHAVE
NAVAJO
PIMA
PINAL
SANTA CRUZ
YAVAPAI
YUMA
Zip Code:
Contact Details:
Type1:
--select--
Facility
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Signatory Physician
Contact for HL7 Data
Office Manager
Contact First Name1,
Middle Initial 1,
and Last Name 1:
Phone Number1:
Phone Number Extension1:
Fax Number1:
Email Address1:
Completed Annual Training Requirements
Method of Training Completion
--select--
AIPO Train - Arizona VFC Training
CDC - "You Call the Shots"
Type2:
--select--
Facility
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Signatory Physician
Contact for HL7 Data
Office Manager
Contact First Name2,
Middle Initial 2,
and Last Name 2:
Phone Number2:
Phone Number Extension2:
Fax Number2:
Email Address2:
Completed Annual Training Requirements
Method of Training Completion
--select--
AIPO Train - Arizona VFC Training
CDC - "You Call the Shots"
Type3:
--select--
Facility
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Signatory Physician
Contact for HL7 Data
Office Manager
Contact First Name3,
Middle Initial 3,
and Last Name 3:
Phone Number3:
Phone Number Extension3:
Fax Number3:
Email Address3:
Completed Annual Training Requirements
Method of Training Completion
--select--
AIPO Train - Arizona VFC Training
CDC - "You Call the Shots"
Type4:
--select--
Facility
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Signatory Physician
Contact for HL7 Data
Office Manager
Contact First Name4,
Middle Initial 4,
and Last Name 4:
Phone Number4:
Phone Number Extension4:
Fax Number4:
Email Address4:
Completed Annual Training Requirements
Method of Training Completion
--select--
AIPO Train - Arizona VFC Training
CDC - "You Call the Shots"
Type5:
--select--
Facility
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Signatory Physician
Contact for HL7 Data
Office Manager
Contact First Name5,
Middle Initial 5,
and Last Name 5:
Phone Number5:
Phone Number Extension5:
Fax Number5:
Email Address5:
Completed Annual Training Requirements
Method of Training Completion
--select--
AIPO Train - Arizona VFC Training
CDC - "You Call the Shots"