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Adult Vaccine Program IR-ml7 <br />Office of Immunization and Child Profile <br />AVP Provider Agreement 2019 <br />imealth <br />INSTRUCTIONS <br />Providers participating in the Adult Vaccine Program (AVP) are required to enroll in the program annually. <br />Complete and send in this enrollment form via email(WAChildhoodVaccineg@dyh.wa.goy) or fax (Attn: <br />Adult Vaccine Program at 360.236.3811). For more program information, please review the AVP User <br />Manual. <br />STEP 1: Provide facility information, vaccine delivery information, and certify. <br />FACILITY INFORMATION <br />Facility Name: yts ,4r,4Pub11C Qeaht' a.e ..f. <br />PIN: 1&3 00® <br />Address: 5b% N gnun► ! �e (02 <br />City: El e175 u State: <br />zip: gdg)7� <br />VACCINE DELIVERY ADDRESS <br />Shipping Address:(73 41 e,niemf S -k /a2 <br />City: �� .?Y) W PAzip: �j �2lo <br />Telephone: 50 °1- 9(v 2 r ASIS Fax:,60q - q.33 - 5,2`6 <br />Primary Contact Name: --ri rn Ro Backup Contact Name/I: L12 �%j)i�,kr <br />Email: -Lif'►').>Y� 1 eLo, lei � 0S, W, -4-V$ Email: l 2•i.U�1Vt �,.Co.%i' �AS, ivGr,✓5 <br />VACCINE DELIVERY TIMES (Specify all days and hours your facility is available to receive vaccine. Providers are required <br />to be available for vaccine deliveries a minimum of four consecutive hours, two days a week, excluding Mondays). <br />MondayTuesday Wednesday Thursday N Friday <br />9 oa AM cl b° AM I °a AM to AM �% °0 AM <br />to to to to to <br />I f <br />7 90 PM 'f 00 PM aa PM 30PM 06PM <br />CERTIFICATION <br />Your participation in the 2019 Adult Vaccine Program (AVP) is appreciated. The Washington State <br />Department of Health (DOH) purchases adult vaccine to protect adults who could otherwise not afford to be <br />vaccinated. Increasing access to vaccines protects communities against vaccine preventable diseases. This <br />Provider Agreement specifies the conditions of participation in the AVP in Washington State. The agreement <br />must be signed and submitted to the Office of Immunization and Child Profile prior to receipt of vaccine. <br />y I certify that the above delivery address, dates and times to receive vaccine shipments are correct. I agree <br />to notify DOH immediately if any of my information changes. <br />�I understand and accept the conditions of this agreement and agree to comply with these requirements <br />on behalf of myself and all the practitioners associated with this facility. I agree to inform all providers in the <br />facility of their obligations under the agreement. DOH may terminate this agreement at any time for failure <br />to comply with these requirements. I may terminate this agreement at any time for personal reasons. <br />For people with disabilities, this document is available upon request in other formats. <br />To submit a request, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-637. January 2019. <br />Page 1 of 3 <br />