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II <br />8. I will distribute the current Vaccine Information Statements (VIS) each time a vaccine is administered and <br />maintain records in accordance with the National Childhood Vaccine Injury Act (NCVIA), which includes <br />reporting clinically significant adverse events to the Vaccine Adverse Event Reporting System (VAERS). <br />9. I will comply with the requirements for vaccine management including: <br />A. Ordering vaccine and maintaining appropriate vaccine inventories; <br />8 . Not storing vaccine in dormitory-style units at anytime; <br />C. Storing vaccine under proper storage conditions at all times. Refrigerator and freezer vaccine storage <br />units and temperature monitoring equipment and practices must meet Washington State Childhood <br />Vaccine Program storage and handling requirements; <br />D. Returning all spoiled/expired public vaccines to CDC's centralized vaccine distributor within six <br />months of spoilage/expiration. <br />10. I agree to operate within the VFC program in a manner intended to avoid fraud and abuse. Consistent with <br />"fraud " and "abuse" as defined in the Medicaid regulations at 42 CFR § 455.2, and for the purposes of the VFC <br />Program: <br />Fraud -is an intentional deception or misrepresentation made by a person with the knowledge that the <br />deception could result in some unauthorized benefit to himself or some other person . It includes any act that <br />constitutes fraud under applicable federal or state law . <br />Abuse -provider practices that are inconsistent with sound fiscal, business, or medical practices and result in <br />an unnecessary cost to the Medicaid program, (and/or including actions that result in an unnecessary cost to <br />the immunization program , a health insurance company, or a patient); or in reimbursement for services that <br />are not medically necessary or that fail to meet professionally recognized standards for health care. It also <br />includes recipient practices that result in unnecessary cost to the Medicaid program. <br />11. I will participate in VFC program compliance site visits including unannounced visits, and other educational <br />opportunities associated with VFC program requirements. <br />12. For pharmacies, urgent care, or school located vaccine clinics, I agree to: <br />A. Vaccinate all "walk-in" VFC-eligible children; and <br />B. Will not refuse to vaccinate VFC-eligible children based on a parent's inability to pay the <br />administration fee . <br />Note: "Walk-in" refers to any VFC eligible child who presents requesting a vaccine; not Just established <br />patients. "Walk-in" does not mean that a provider must serve VFC patients without an appointment. If a <br />provider's office policy is for all patients to make an appointment to receive immunizations then the policy <br />would apply to VFC patients as well. <br />13. I understand this facility or the Washington State Childhood Vaccine Program (CVP) may terminate this <br />agreement at any time. If I choose to terminate this agreement, I will properly return any unused federal <br />vaccine as directed by the CVP. <br />By signing this form, I certify on behalf of myself and all immunization providers In this facility, I have read and <br />agree to the Vaccines for Children enrollment requirements listed above and understand I am accountable (and <br />each listed provider is Individually accountable) for compliance with these requirements. <br />Signature: Date :