Washington State DOH Immunization Program

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2016 WASHINGTON STATE DEPARTMENT OF HEALTH IMMUNIZATION PROGRAM To receive publicly funded vaccines at no cost, I agree to the following conditions, on behalf of myself and all the practitioners, nurses, and others associated with the health care facility of which I am the medical director or equivalent: 1. 1 will annually submit a provider profile representing populations served by my practice/facility. I will submit more frequently if 1) the number of children served changes or 2) the status of the facility changes during the calendar year. 2. 1 will screen patients and document eligibility status at each immunization encounter for VFC eligibility (i.e., federally or state vaccine -eligible) and administer VFC-purchased vaccine by such category only to children who are 18 years of age or younger who meet one or more of the following categories: A. Federally Vaccine -eligible Children (VFC eligible) 1. Are an American Indian or Alaska Native; 2. Are enrolled in Medicaid; 3. Have no health insurance; 4. Are underinsured: A child who has health insurance, but the coverage does not include vaccines; a child whose insurance covers only selected vaccines (VFC-eligible for non -covered vaccines only). Underinsured children are eligible to receive VFC vaccine only through a Federally Qualified Health Center (FQHC), or Rural Health Clinic (RHC) or under an approved deputization agreement State Vaccine -eligible Children 1. In addition, to the extent that my state designates additional categories of children as "state vaccine -eligible", I will screen for such eligibility as listed in the addendum to this agreement and will administer state -funded doses (including 317 funded doses) to such children. Children aged 0 through 18 years that do not meet one or more of the eligibility federal vaccine categories (VFC eligible), are not eligible to receive VFC-purchased vaccine. 3. For the vaccines identified and agreed upon in the provider profile, I will comply with immunization schedules, dosages, and contraindications that are established by the Advisory Committee on Immunization Practices (ACIP) and included in the VFC program unless: a) In the provider's medical iudgment, and in accordance with accepted medical practice, the provider deems such compliance to be medically inappropriate for the child; b) The particular requirements contradict state law, including laws pertaining to religious and other exemptions. 4. 1 will maintain all records related to the VFC program for a minimum of six years and upon request make these records available for review. VFC records include, but are not limited to, VFC screening and eligibility documentation, billing records, medical records that verify receipt of vaccine, vaccine ordering records, temperature logs, and vaccine purchase and accountability records. 5. 1 will immunize eligible children with publicly supplied vaccine at no charge to the patient for the vaccine, 6. 1 will notcl�e_a vaccine administration fee to non -Medicaid federal vaccine eligible children that exceeds the administration fee cap of $23.44 per vaccine dose. For Medicaid children, I will accept the DOH 348-022 revised for 2016 If you have a disability and need this document in a different format, please call 1-800- 525-0127 (TDD/TTY 1-800-833-6388).