Provider Agreement Immunization Program (2)

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2018 WASHINGTON STATE DEPARTMENT OF HEALTH OFFICE OF IMMUNIZATION AND CHILD PROFILE PROVIDER AG REEM ENI EQ B RECEIPT Of PUBUCLY SUPPUED VACCINE Organization Name: KITTITAS COUNTY HEALTH DEPARTMENT Clinic/Facility Name: KITTITAS COUNTY HEALTH DEPARTMENT PIN: 163000 Ya cc ne o e,111,e ry~ Address Line #1: 507 N. NAN UM SUITE 102 Address Line #2 : City: ELLENSBURG State: WA Zip Code : 98926 Email Address · TIM ROTH @ CO ,KITTITAS.WA.US Primary Vaccine Coordinator Name: TIM ROTH Phone Number: (509)962.7634 Fax Number: (S 0.&)&~,8246 Email Address : TIM.ROTH @CO .K ITTITAS .WA us IBJ Check if comp liited annual tra inin g ('e(!U lre tne nts Ma \h ng Add ress m dfJfere ntl Address Line #1 : 507 N NANUM SUITE 102 Address Line #2 : City : ELLENSBURG State : WA Zip Code : 98926 Back-up Vaccine Coordinator Name : uz WHITAKER Phone Number : (509)962-7068 Fax Number: (509)933-8246 Emall Address : Ll Z.WHli ,\)(ER @CO .KITTITAS.WA.US [XI Check if comp1 er11a arinua 1 tram mg requirements 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): ()(: Mm 9 a.m. to 4 p.m. / _____ to ____ X Wed 9 a.m . to 4 p.m. ___ to ___ _ ~ TUI!$ El a.ni. 11,1 •I p.m, / _____ to ____ lll( Thurs 9 a.m . to 4 p.m. ~ FIi 9a,m. 10 '1p.m. , _____ .10 ___ _ ____ to ___ _ 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 chang es, and understand tha t this prac11ce may he required to reimburse the state for vaccines that are wasted due to delivery failure resulting from -an Ina ccurate addres s. Type of Facility: PUBLIC_PUBLIC_HEALTH_DEPARTMENT _CLINIC Vaccines Offered : ~ All ACIP Recommended Vaccines O Select Vaccines as a Specialty Prov ider (list the selected vaccines): As a condition for receiving publicly funded vaccines from the WASHINGTON CHILDHOOD VACCINE PROGRAM, this practice agrees to the FEDE R Al . AND STATE REQUIREM ENTS attached in DOH publication #348-022 . This agreement is between the Washington State Department of Health and the clinic site listed above . By signing this agreement and receiving vaccines from the state, I understand an d accapl the conditions of this agreement and agree to com ply with these requirements on behalf of myself and all the practitioners as sociated with this medical office . I agree to notify 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 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 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 to comply with these requirements. I may terminate this agreement at any time for personal reasons. I have selected to be certified to receive frozen vaccines from the Washington State Childhood Vaccine Program. I certify that appropriate storage is in place for frozen vaccine. HEAL TH OFFICER Title r t,D. reement must be signed by a provider who is licensed in the state f Washington to prescribe vaccines and is responsible for making decision about the clinic and its operations. The provider must print and sign the agreement and keep the signed original on site at their clinic.