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2018 <br />WASHINGTON STATE DEPARTMENT OF HEALTH <br />OFFICE OF IMMUNIZATION AND CHILD PROFILE <br />PROVIDER AG REEM ENI EQ B RECEIPT Of PUBUCLY SUPPUED VACCINE <br />Organization Name: KITTITAS COUNTY HEALTH DEPARTMENT <br />Clinic/Facility Name: KITTITAS COUNTY HEALTH DEPARTMENT <br />PIN: 163000 <br />Ya cc ne o e,111,e ry~ <br />Address Line #1: 507 N. NAN UM SUITE 102 <br />Address Line #2 : <br />City: ELLENSBURG <br />State: WA <br />Zip Code : 98926 <br />Email Address · TIM ROTH @ CO ,KITTITAS.WA.US <br />Primary Vaccine Coordinator Name: TIM ROTH <br />Phone Number: (509)962.7634 <br />Fax Number: (S 0.&)&~,8246 <br />Email Address : TIM.ROTH @CO .K ITTITAS .WA us IBJ Check if comp liited annual tra inin g ('e(!U lre tne nts <br />Ma \h ng Add ress m dfJfere ntl <br />Address Line #1 : 507 N NANUM SUITE 102 <br />Address Line #2 : <br />City : ELLENSBURG <br />State : WA <br />Zip Code : 98926 <br />Back-up Vaccine Coordinator Name : uz WHITAKER <br />Phone Number : (509)962-7068 <br />Fax Number: (509)933-8246 <br />Emall Address : Ll Z.WHli ,\)(ER @CO .KITTITAS.WA.US [XI Check if comp1 er11a arinua 1 tram mg requirements <br />Sh fpi~lr111 Pav.;; and ]mes C\'ib eo th e ra c1il1y wit be open 10 r:e s;eive va cg/ne sh1c ments): <br />()(: Mm 9 a.m. to 4 p.m. / _____ to ____ X Wed 9 a.m . to 4 p.m. ___ to ___ _ <br />~ TUI!$ El a.ni. 11,1 •I p.m, / _____ to ____ lll( Thurs 9 a.m . to 4 p.m. <br />~ FIi 9a,m. 10 '1p.m. , _____ .10 ___ _ <br />____ to ___ _ <br />I ag ree to notify my local he alth de partm ent or the state Departm e nt of Health lmm odlately if my vaccine delivery address <br />chang es, and understand tha t this prac11ce may he required to reimburse the state for vaccines that are wasted due to <br />delivery failure resulting from -an Ina ccurate addres s. <br />Type of Facility: PUBLIC_PUBLIC_HEALTH_DEPARTMENT _CLINIC <br />Vaccines Offered : ~ All ACIP Recommended Vaccines O Select Vaccines as a Specialty Prov ider (list the selected vaccines): <br />As a condition for receiving publicly funded vaccines from the WASHINGTON CHILDHOOD VACCINE PROGRAM, this practice <br />agrees to the FEDE R Al . AND STATE REQUIREM ENTS attached in DOH publication #348-022 . This agreement is between the <br />Washington State Department of Health and the clinic site listed above . <br />By signing this agreement and receiving vaccines from the state, I understand an d accapl the conditions of this agreement and agree <br />to com ply with these requirements on behalf of myself and all the practitioners as sociated with this medical office . I agree to notify <br />the s ta te De p artment-of Hea lt h Immediately and update my p ro \llde'r ag reement if myclinlc/p ractlce n.itne ch anges . m y clinic or <br />vaccine deli very add ress ch ange_s , or the signator y below leaves t he pracl ce or l s re place d . T he state Depa rtmen t of Health or the <br />local he alt h jurisdi ction m ey teml:)o ra rily disco ntin ue the prov is loo of vaccine or may term !na te th is -ag reem en t al an_y ti me for failure <br />to comply with these requirements. I may terminate this agreement at any time for personal reasons. <br />I have selected to be certified to receive frozen vaccines from the Washington State Childhood Vaccine Program. I certify that <br />appropriate storage is in place for frozen vaccine. <br />HEAL TH OFFICER <br />Title r t,D. <br />reement must be signed by a provider who is licensed in the state f Washington to prescribe <br />vaccines and is responsible for making decision about the clinic and its operations. <br />The provider must print and sign the agreement and keep the signed original on site at their clinic.