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2017 <br />WASHINGTON STATE DEPARTMENT OF HEALTH <br />OFFICE OF IMMUNIZATION AND CHILD PROFILE <br />PROYIDER AGREEMENT FOB REC EIPT OF PUBLICLY SUPPLIED YACCINE <br />Organization Name: KITTITAS VALLEY HEALTHCARE <br />Clinic/Facility Name: KITTITAS COUNTY PUBLIC HEALTH <br />PIN: 163000 <br />Vaoeine DeliVe ry Address <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 .ROTH@CO.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 IXI Check if completed annual training requirements <br />Malll hg Address (If 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 .wH·ITAKER @CO.KITTITAS.wA.US IXl Check if completed annual training requirements <br />Shipping DaYS aod TIines ,(when the facilltv -M il be open .to receive vaccine shipments); <br />tX Man 9 a.m. 10 4 p.m . I 10 ~ Wed 9 a.m. 10 4 p.m. ____ 10 ___ _ <br />~ Tu es 9 a.m . to 4 p.m . l to ~ Thurs 9 a.m. 10 4 p.m. <br />~ Fri 9a,01 . 10 4 p .m . /. 10 ___ _ <br />____ 10 ___ _ <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_.HEAL TH _DEPARTMENT_CLlNIC <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 FEDERAL AND STATE REaUIBliMENTS 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 and accept the conditions of this agreement and agree <br />to com ply 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 agreement if my clinic/practice name changes, my clinic 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 terminate this agreement at any time for failure <br />to com ply with these requirements. I may term inate this agreement at any time for personal reasons. <br />Title <br />he provider agreement must be signed by a provider who is licensed in the state of ash i gton to <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.