Return to previous page

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

Site Information

Type of Site*

Site name*

Organizational Name

Public or Private*

Specialty Type*

Enter Street Address (P O Box not accepted)*

City*

State*

Address 2: Suite, Unit, Building, etc. (P O Box not accepted)

County*

Zipcode*

Phone Number*

Extension

Fax Number

Site NPI* (Look Up)

Site Agreement

The Alabama Department of Public Health (ADPH), Immunization Division (IMM), Immunization Patient Resources with Integrated Technology (ImmPRINT) is a confidential computerized immunization registry and is available as a single immunization source for all immunization data users and sites, see Chapter 420-6-2, Exchange of Immunization Information and Operation of the Alabama Immunization Registry. All Site Administrators must understand, educate staff, and agree to the following on behalf of the Site:

ImmPRINT data is the property of the Alabama Department of Public Health (ADPH). ADPH retains all rights to ImmPRINT and grants the immunization data users a non-exclusive license to use the service and data.
Notify ADPH Immunization Division (1-800-469-4599) of any unauthorized disclosure or dissemination of confidential information, which may violate state or federal law and result in criminal or civil penalties.
Schedule and participate in initial and annual training within 30 days of contact from ADPH staff, and Webinars on an as needed basis on the ADPH ImmPRINT Webpage.
Monitor and maintain active users at this site. This includes resetting their passwords and inactivating staff who no longer work for this site.
ImmPRINT is for the receipt, input, and/or correction of patient demographic and/or vaccine information by direct entry, Health Level 7 (HL7) message interface, or another ADPH Immunization Division approved method. Each site should strive to submit all immunization information (historical and/or current) to ImmPRINT within 72 hours after obtaining the data.
Access ImmPRINT to assess patient immunization information, avoid unnecessary immunizations, confirm compliance with mandatory immunization requirements, and control disease outbreaks.
Ensure all data users are educated to protect their ImmPRINT Login ID and Password and not share it with other staff.
Assign a site administrator to train and activate new site staff in a timely manner, and deactivate site staff who no longer work for this site within 1 business day to maintain confidentiality and security of ImmPRINT.
Allow parents/guardians/patients to inspect, copy, and if necessary, amend or correct patient’s immunization record when they can demonstrate the vaccine documentation is incorrect.
Site or ADPH may terminate this agreement at any time for failure to comply with these requirements.

All Sites Administrator for sites who submit HL7 data must also understand and agree to the following:

Run HL7 error reports (Connectivity, Vaccine, Error, Ongoing Submission, and Ongoing Submission by NPI) monthly for each site to ensure the data coming in is accurate.
Submit vaccine data continuously by site. If ImmPRINT has not received vaccine data for 6 continuous months, the site will be deactivated.
Notify ImmPRINT in advance when switching Electronic Health Record (EHR) vendor.

Medical Authority Information

Each physician, physician assistant, and nurse practitioner who administers vaccines must be submitted.

First Name	Last Name	Provider Type	Prof. Title	NPI Number	Email

Add New Row Remove Row

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

Electronic Signature *

Email *

Direct Phone *

Today's Date

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

Cancel

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

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