Washington State DOH Immunization Program

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2016 WASHINGTON STATE DEPARTMENT OF HEALTH OFFICE OF IMMUNIZATION AND CHILD PROFILE PROVIDER AGREEMENT FOR RECEIPT OF PUBLICLY SUPPLIED VACCINE Organization Name: KwriTAS VALLEY HEALTHCARE Clinic/Facility Name: KITTITAS COUNTY PUBLIC HEALTH PIN: 163000 Vaccine Delivery Address Address Line #1: 507 N NANUM ST Address Line #2: SUITE 102 City: ELLENSBURG State: wA Mailina Address (if different) Address Line #1: 507 N NANUM ST Address Line #2: SUITE 102 City: ELLENSBURG State: WA Zip Code: 98926 Zip Code: 96926 Email Address: TIM. ROTH()CO.KITTITAS.WA.US Primary Vaccine Coordinator Name: TIM ROTH Phone Number: 509)962-7634 Fax Number: (509)933-8246 Email Address: TIM.ROTH@CO.KITTITAS.WA.US 0 Check if completed annual training requirements Back-up Vaccine Coordinator Name: LIZ WHITAKER Phone Number: (509)962-7068 Fax Number: (509)933-8246 Email Address: LIZ.WHITAKER@CO.KITTITAS.WA.US X❑ Check if completed annual training requirements Shipoing QaA arjdTimes (when the fa ilii II c lve vac ine shiments X Mon 9 a.m. to 4 p.m. / to Wed 9 a.m. to 4 p.m. / to Tws 9 a.m. to_ 4 p•m- to X Thurs 9 a.m. to 4 p.m. / to X Fd 9 a.m. to 4 p.m, la I agree to notify my local health department or the state Department of Health immediately if my vaccine delivery address changes, and understand that this practice may be required to reimburse the state for vaccines that are wasted due to delivery failure resulting from an inaccurate address. Type of Facility: PUBLIC—PUBLIC HEALTH DEPARTMENT_ CLINIC Vaccines Offered: 6 All ACIP Recommended Vaccines O Select Vaccines as a Specialty Provider (list the selected vaccines): As a condition for receiving publicly funded vaccines from the WASHINGTON CHILDHOOD VACCINE PROGRAM, this practice agrees to the FEDERAL AND STATE REQUIREMENTS attached in DOH publication #348-022. This agreement is between the Washington State Department of Health and the clinic site listed above. By signing this agreement and receiving vaccines from the state, I understand and accept the conditions of this agreement and agree to comply with these requirements on behalf of myself and all the practitioners associated with this medical office. I agree to notify the state Department of Health immediately and update my provider agreement if my clinic/practice name changes, my clinic or vaccine delivery address changes, or the signatory below leaves the practice or is replaced. The state Department of Health or the local health jurisdiction may temporarily discontinue the provision of vaccine or may terminate this agreement at anytime for failure to comply with these requirements. I mayterminatethis agreement at anytime for personal reasons. I have selected to be certified to receive frozen vaccines from the Washington State Childhood Vaccine Program. I certify that appropriate storage is in place for frozen vaccine. MARK LARSON Full name of Provider with prescriptive authority* Signature of Provider with prescriptive authority* Title National Provider I.D. Date *The provider agreement must be signed by a provider who is licensed in the state of Washington to prescribe vaccines and is responsible for making decision about the clinic and its operations. The provider must print and sign the agreement and keep the signed original on site at their clinic.