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2016 <br />WASHINGTON STATE DEPARTMENT OF HEALTH <br />OFFICE OF IMMUNIZATION AND CHILD PROFILE <br />PROVIPER AGREEM EN! FOR RECEIP! OF pUBLICLY SUPPLIEP VACCINE <br />Organization Name: KITTITAS VALLEY HEALTHCARE <br />Clinic/Facility Name: KITTITAS COUNTY PUBLIC HEALTH <br />PIN: 163000 <br />Vaccioe DellvervAddress <br />Address Line #1: 507 N NANUM ST <br />Address Line #2: SUITE 102 <br />City: ELLENSBURG <br />State: WA <br />Zip Code: 98926 <br />Email Address :TIM .ROTHallCO.KITTITAS.wA .US <br />Primary Vaccine Coordinator Name: TIM ROTH <br />Phone Number: (509)962.7634 <br />Fax Number: (509)933-8246 <br />Email Address:TIM .ROTH@CO .KITTITAS .WA.US <br />[Xl Check if completed annual training requirements <br />MaHlng Addres s (I! different) <br />Address Line #1: 507 N NANUM ST <br />Address Line #2: SUITE 102 <br />City: ELLENSBURG <br />State: WA <br />Zip Code: 98926 <br />Back-up Vaccine Coordinator Name: LIZ WHITAKER <br />Phone Number: (509)962-7068 <br />Fax Number : (509)933-8246 <br />Email Address:LlZ.wHITAKER @CO.KITTITAS.wA.US IX] Check if completeo annual tralOing reqUirements <br />Shipping Days and Tim es (when Ulle facl!1!y wi ll be open to rece lye vacCine shipmen ts): <br />¢( Man 9 a .m. to 4 p.m. I _____ to ~ Wed 9 a.m. to 4 p.m. ____ 1,0 ___ _ <br />~ Tues ·9 a .m. 10 4 p.m. I to \II! Thurs 9 a.m. to 4 p .m. <br />~ Fri 9 'a .01 . 10 4 p.m. 10 ___ _ <br />____ 1,0 ___ _ <br />I agree to notify my local health department or the state Department of Health immediately if my vaccine delivery address <br />changes, and understand that this practice may be required to reimburse the state for vaccines that are wasted due to <br />delivery failure resulting from an inaccurate address. <br />Type of Facility : PUBLlC_PUBLlC .• HEALTH _DEPARTMENT _CLINIC <br />Vaccines Offered: ~ All ACIP Recommended Vaccines 0 Select Vaccines as a Specialty Provider (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 fEPERAL ANP STATE REQUIREMENIS attached in DOH publication #348-022. This agreement is between the <br />Washington State Departmentof Health and the clinic site listed above. <br />By signing this agreement and receiving vaccines from the state , I understand and accept the conditions of this agreem ent and agree <br />to comply with these requirements on behalf of myself and all the practitioners associated with this medical office . I agree to notify <br />the state Department of Health immediately and update my provider agreem ent if my clinic/practice name changes, myelinic or <br />vaccine delivery address changes, or the signatory below leaves the practice or is replaced . The state Department of Health or the <br />local health jurisdiction may temporarily discontinue the provision of vaccine or may term inate this agreement at any tim e for failure <br />to com ply with these requirements. I may terminate this agreement at any tim e 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 />MD <br />Title <br />~ at U(i <br />// ·Tl (nr i de r ag r. e t must be signed by a provider who is licensed in the state of ash ington to prescribe <br />I' vac . es and is responsible for making decision about the clinic and its operations. <br />The provi er must print and sign the agreement and keep the signed original on site at their clinic.