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2016 <br />WASHINGTON STATE DEPARTMENT OF HEALTH <br />IMMUNIZATION PROGRAM <br />To receive publicly funded vaccines at no cost, I agree to the following conditions, on behalf of myself and all <br />the practitioners, nurses, and others associated with the health care facility of which I am the medical director <br />or equivalent: <br />1. I will annually submit a provider profile representing populations served by my practice/facility. I will <br />submit more frequently if 1) the number of children served changes or 2) the status of the facility changes <br />during the calendar year . <br />2. I will screen patients and document eligibility status at each immunization encounter for VFC eligibility <br />(i.e., federally or state vaccine-eligible) and administer VFC-purchased vaccine by such category only to <br />children who are 18 years of age or younger who meet one or more of the following categories: <br />A. Federally Vaccine-eligible Children (VFC eligible) <br />1. Are an American Indian or Alaska Native; <br />2 . Are enrolled in Medicaid; <br />3. Have no health insurance; <br />4. Are underinsured: A child who has health insurance, but the coverage does not include <br />vaccines; a child whose insurance covers only selected vaccines (VFC-eligible for non-covered <br />vaccines only). Underinsured children are eligible to receive VFC vaccine only through a <br />Federally Qualified Health Center (FQHC), or Rural Health Clinic (RHC) or under an approved <br />deputization agreement <br />B. State Vaccine-eligible Children <br />1. In addition, to the extent that my state designates additional categories of children as "state <br />vaccine-eligible", I will screen for such eligibility as listed in the addendum to this agreement <br />and will administer state-funded doses (including 317 funded doses) to such children . <br />Children aged 0 through 18 years that do not meet one or more of the eligibility federal vaccine <br />categories (VFC eligible), are not eligible to receive VFC-purchased vaccine. <br />3. For the vaccines identified and agreed upon in the provider profile, I will comply with immunization <br />schedules, dosages, and contra indications that are established by the Advisory Committee on <br />Immunization Practices (ACIP) and included in the VFC program unless: <br />a) In the provider's medicalludgment, and in accordance with accepted medical practice, the provider <br />deems such compliance to be medically inappropriate for the child; <br />b) The particular requirements contradict state law, including laws pertaining to religious and other <br />exemptions . <br />4. I will maintaln all records related to the VFC pr.ogram for a minimum of siX years and upon request make <br />these records available for review. VFC records include, but are not limited to, VFC screening and eligibility <br />documentation, billing records, medical records that verify receipt of vaccine, vaccine ordering records, <br />temperature logs, and vaccine purchase and accountability records. <br />5. I will immunize eligible children with publicly supplied vaccine at no charge to the patient for the vaccine. <br />6. I will riot charge a vaccine administration fee tb non-Meclicaid federal vaccine eliSible children that <br />exceeds the administration fee cap of-$73.44 .per vaccine dose . For Medicaid children, I will accept the <br />DOH 348-022 revised for 2016 If you have a disability and need this document in a different format, please call 1-800- <br />525-0127 (TDDfTTY 1-800-833-6388). <br />/'I, I. I' t ,