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Adult Vaccine Progra* lnUn úTa;mOffice of lmmunization and Child Profile <br />AVP Provider Agreement 2Ot9 <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 (WAChildhoodVaccines@doh.wa.gov) 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 />FACITITY INFORMATION <br />Facility Name: i1,;,1á c.llh PIN: lü3 ooa <br />Address:Sol V l,,lqnun, S+e ioL <br />City:Elt(hsbura State: lil fr zip: q#12þ <br />VACCINË DELIVERY ADDRESS <br />ShippingAddress: Epl Ål Alnt,nr, S.it tDL <br />€ity Elt ¿"tL*ä pù zip: qSqLb <br />Telephone: 50q - qbf-l€tl Fax: 60e. qß- Bl'lt, <br />Primary Contact Name: .1,- Rr+h <br />Emait: *înrrv*h Q, ¿o " L¡Il,¿rs, wtr , vs <br />Backup Contact Narne: L¡z lrtlh¡Jøh.Email: l¡z.w\.,iloL* e* ^ L;li-,¿ut, þ¡ø, ut¡ <br />VACCINE DEUVERY flMES (Specifo all days and hours your facility is available to receive vaccine. Providers are required <br />to be available for vacclne deliveries a minimum of four consecutlve hours, two days a weeÇ excluding Mondays). <br />[Jtrrtonday ffi ruesday lX[wednesday ffithursday ffi rrioay <br />I u' Rn¡ <br />to <br />lou pvr <br />700 <br />to <br />. t90.l <br />AM <br />PM <br />?0" au <br />4 <br />to <br />aO <br />PM <br />c/* *w <br />4 <br />to <br />Þ0 <br />PM <br />Qol e¡vt <br />4 <br />to <br />0ô <br />PM <br />CERTIFICAT¡ON <br />Your participation in the 2019 Adult Vaccine Program (AVP) is appreciated. The Washington State <br />Department of Health (DOH) purchases adult vaccíne to protect adults who could otherwíse not afford to be <br />vacc¡nated. lncreasing access to vaccines protects communities against vaccine preventable diseases. This <br />Provider Agreement specifies the conditions of participation ín the AVP in Washington State. The agreement <br />must be signed and submitted to the Office of lmmunization and Chíld Profile prior to receipt of vaccine. <br />[l I certífy that the above delivery address, dates and times to receive vaccíne shipments are correct. I agree <br />to notify DOH immediately if any of my information changes. <br />Kt 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 thís 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 l'lDD/TW call 7ttl. DOH 348-637. January 2019. <br />Page 1 of 3