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Site Enrollment Agreement
Fields marked with an asterisk (*) are required.

Site Information
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Site NPI* (Look Up)
VFC PIN
 
Vaccine For Children (VFC) Provider
Are you registering for
Meaningful Use (HL7)
ImmPRINT Site Administrator Contact Information
Site Administrator Name*
Site Administrator E-Mail*
Site Administrator Phone*
Site Agreement
Medical Authority Information
Healthcare provider must complete for each physician, physician assistant, and nurse practitioner who administers vaccines.
First NameLast NameProvider TypeProf. TitleNPI NumberEmail
If you have more than 30 providers, you may attach an Excel spreadsheet with the information in the above table instead of entering data manually. Please include all fields listed. At least one provider must be listed in the table.
Authorization


By selecting "I agree" below, I legally acknowledge and agree to the terms of the Site Agreement.

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