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2017 <br />WASHINGTON STATE DEPARTMENT OF HEALTH <br />OFFICE OF IMMUNIZATION AND CHILD PROFILE <br />Organization Name: KITTITAS VALLEY HEALTHCARE <br />Clinic/Facility Name: KITTITAS COUNTY PUBLIC HEALTH <br />PIN: 163000 <br />Vaccine Delivery Address <br />Address Line #1: 507 N NANUM ST <br />Address Line #2: SUITE 102 <br />City: ELLENSBURG <br />State: wA <br />Zip Code: 98926 <br />Email Address: TIM.ROTH@CO.KITTITAS.WA.US <br />Primary Vaccine Coordinator Name: TIM ROTH <br />Phone Number: 509)962-7634 <br />Fax Number: (509)933-8246 <br />Email Address: TIM.ROTH@CO KITTITAS.WA.US <br />0 Check if completed annual training requirements <br />Mail ingAddr_ess (if different] <br />Address Line #1: 507 N NANUM ST <br />Address Line #2: SUITE 102 <br />City: ELLENSBURG <br />State: WA <br />Zip Code: 98926 <br />Back-up Vaccine Coordinator Name: LIZ WHITAKER <br />Phone Number: (509)962-7068 <br />Fax Number: (509)933-8246 <br />Email Address: LIZ.WHITAKER@CO'KITTITAS.WA.US <br />N Check if completed annual training requirements <br />Shipping Das and Times when the facility will be ppon to re_C_eive vaccine shipments): <br />X Mon 9 a.m. to 4 p.m. / to t Wed 9 a.m. to 4 p.m. / to <br />X Tues 9 a.m. to 4 p.m. / to X Thurs 9 a.m. to 4 p.m. / to <br />X Fri 9 a.m. to 4 p.m. /— - - to <br />I agree to notify my local health department or the state Department of Health immediately if my vaccine delivery address <br />changes, and understand that this practice may be required to reimburse the state for vaccines that are wasted due to <br />delivery failure resulting from an inaccurate address. <br />Type of Facility: PUBLIC-PUBLIC-..HEALTH--DEPARTMENT-CLINIC <br />Vaccines Offered: 6 All ACIP Recommended Vaccines O Select Vaccines as a Specialty Provider (list the selected vaccines): <br />As a condition for receiving publicly funded vaccines from the WASHINGTON CHILDHOOD VACCINE PROGRAM, this practice <br />agrees to the FFQERAL AND STATE REQUIREMENT5 attached in DOH publication #348-022. This agreement is between the <br />Washington State Department of Health and the clinic site listed above. <br />By signing this agreement and receiving vaccines from the state, I understand and accept the conditions of this agreement and agree <br />to comply with these requirements on behalf of myself and all the practitioners associated with this medical office, I agree to notify <br />the state Department of Health immediately and update my provider agreement if my clinic/practice name changes, my clinic or <br />vaccine delivery address changes, or the signatory below leaves the practice or is replaced. The state Department of Health or the <br />local health jurisdiction may temporarily discontinue the provision of vaccine or may terminate this agreement at any time for failure <br />to comply with these requirements. I may terminate this agreement at anytime for personal reasons. <br />I have selected to be certified to receive frozen vaccines from the Washington State Childhood Vaccine Program. I certify that <br />appropriate storage is in place for frozen vaccine. <br />MARKLARSON MD <br />Full name of Provider with prescriptive authority' <br />Title <br />National Provider I.D. <br />Signature of Provider with prescriptive authority" Date <br />"The provider agreement must be signed by a provider who is licensed in the state of Washington to prescribe <br />vaccines and is responsible for making decision about the clinic and its operations. <br />The provider must print and sign the agreement and keep the signed original on site at their clinic. <br />