ࡱ>  @ bjbj{{ }s%     \\\p'''8')LpvD*111(1{4B79uuuuuuu$xR;{u\=@3{4=@=@u  1(1_vGGG=@ 81\(1uG=@uGGk0D\\n(1* ĠM<'A*l$p uv0vmD{IB {H\npp    {\\n,q:d;G<=q:q:q:uupp$&$iG^pp&2009 Influenza A (H1N1) Monovalent Vaccine Michigan Department of Community Health (MDCH) Vaccine Provider Agreement Michigan Care Improvement Registry (MCIR) Site ID #: VFC PIN #:  FORMTEXT      Clinic Name:  FORMTEXT      Contact Name:  FORMTEXT      Delivery Address of Clinic/Site:  FORMTEXT      City:  FORMTEXT      County:  FORMTEXT      Zip code:  FORMTEXT      Phone Number: ( FORMTEXT    )  FORMTEXT     -  FORMTEXT      ext  FORMTEXT      Fax Number: ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     E-mail address:  FORMTEXT       Vaccine may be shipped directly to you by McKesson. Please provide your Clinic/Site delivery hours: Monday: FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PMto FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM Closed for lunch from  FORMTEXT       to  FORMTEXT      Tuesday: FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM to FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM Closed for lunch from  FORMTEXT       to  FORMTEXT      Wednesday: FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM to FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM Closed for lunch from  FORMTEXT       to  FORMTEXT      Thursday: FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM to FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM Closed for lunch from  FORMTEXT       to  FORMTEXT      Friday: FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM to FORMTEXT       FORMCHECKBOX  AM  FORMCHECKBOX  PM Closed for lunch from  FORMTEXT       to  FORMTEXT       Facility Type (check the box that best describes your facility):  FORMCHECKBOX Public Health Department FORMCHECKBOX School-based Clinic  FORMCHECKBOX Public Health Department Satellite Clinic FORMCHECKBOX College/University FORMCHECKBOX Private Practice (Individual or group) FORMCHECKBOX Teen Health Center FORMCHECKBOX Hospital FORMCHECKBOX Correctional Facility FORMCHECKBOX Tribal Health Center FORMCHECKBOX Pharmacy FORMCHECKBOX Federally Qualified Health Center (FQHC) FORMCHECKBOX Other public (specify):  FORMTEXT       FORMCHECKBOX Rural Health Clinic (RHC) FORMCHECKBOX Other private (specify):  FORMTEXT       Specialty Type (check the box that best describes your practice):  FORMCHECKBOX Pediatrics FORMCHECKBOX Family Planning  FORMCHECKBOX Internal Medicine FORMCHECKBOX VNA FORMCHECKBOX OB/GYN FORMCHECKBOX LTC Facility/Nursing Home FORMCHECKBOX Family Practice FORMCHECKBOX Walk-in Center FORMCHECKBOX Multi-Specialty FORMCHECKBOX Other (specify):  FORMTEXT       Your participation in the 2009 Influenza A(H1N1) monovalent vaccine vaccination effort is greatly appreciated as a vital service that will protect individuals and the public against 2009 H1N1 influenza. The 2009 Influenza A(H1N1) monovalent vaccine has been purchased by the federal government as a means of protecting the public against 2009 H1N1 influenza. It is being made available to immunization providers working in partnership with state and local public health departments (LHD) to vaccinate individuals for whom the vaccine is recommended. This Provider Agreement specifies the conditions of participation in the 2009 Influenza A(H1N1) monovalent vaccine vaccination effort in the U.S. and must be signed and submitted to the LHD immunization program prior to receipt of the vaccine. 2009 Influenza A (H1N1) Monovalent Vaccine MCIR Site ID #:  FORMTEXT       Vaccine Provider Agreement Page 2 of 3 VFC PIN #:  FORMTEXT        As an immunization provider, you agree to: Administer the 2009 Influenza A (H1N1) monovalent vaccine according to the recommendations of Centers for Disease Control and Preventions (CDC) Advisory Committee on Immunization Practices. Store and handle the vaccine in accordance with the package insert provided with the vaccine including in compliance with cold chain requirements. (Refrigerator 2-8oC/35-46oF) Provide a current Vaccine Information Statement to each individual before vaccination, and answer questions about the benefits and risks of vaccination, including different indications for live versus inactivated vaccines. Record in the patients medical record or in an office log the date of administration, the site of administration, the vaccine type and lot number, and the name of the immunization provider for each individual vaccinated. The record must be kept for a minimum of three years following vaccination. Report moderate and severe adverse events following vaccination to the Vaccine Adverse Event Reporting System (1-800-822-7967,  HYPERLINK "http://vaers.hhs.gov/contact.htm" http://vaers.hhs.gov/contact.htm). In addition, providers: Can not charge patients, health insurance plans, or other third party payers for the vaccine, the syringes or the needles as these are provided at no cost to the provider. The provider/facility is also prohibited from selling H1N1 vaccine, syringes or needles. May charge a fee for the administration of the vaccine to the patient, their health insurance plan, or other third party payer. The administration fee cannot exceed the regional Medicare vaccine administration fee. If the administration fee is billed to Medicaid, the amount billed cannot exceed the state Medicaid administration fee. May either administer the 2009 Influenza A (H1N1) monovalent vaccine for free to individuals who cannot afford the administration fee, or refer these individuals to a public health department clinic or affiliated public health provider for vaccination. Must report the number of doses of 2009 Influenza A (H1N1) monovalent vaccine administered to individuals as requested by the state or local public health department. Must report to the state health department the number of doses of vaccine that were not able to be used because the vaccine expiration date was exceeded or the vaccine was wasted for other reasons. These doses must be disposed of in accordance with state regulations for biological waste. Are strongly encouraged to provide an immunization record card to the vaccine recipient or parent/guardian to provide a record of vaccination, to serve as an information source if a Vaccine Adverse Event Reporting System report is needed, and to serve as a reminder of the need for a second dose of vaccine (if necessary). 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Enroll in 2009 H1N1 Vaccine Program with Local Health Department (LHD) (see list of LHDs at  HYPERLINK "http://www.malph.org" www.malph.org) and enroll as a provider of the Michigan Care Improvement Registry (MCIR) (see  HYPERLINK "http://www.mcir.org" www.mcir.org). B. Complete population profile information below. C. Order all doses from LHD and allow LHDs to monitor inventories in MCIR. D. Administer the 2009 Influenza A (H1N1) monovalent vaccine consistent with applicable federal and state law. The use of MCIR is required for reporting all doses administered In Michigan. F. Provide access to MDCH and/or LHD to information as may be necessary to document actions taken and services provided under this agreement, or to protect the public health and to prevent or control disease, injury or disability, as authorized by the Health Insurance Portability and Accessibility (HIPAA) Privacy Rule and state law. Population During Flu SeasonEstimated Number Of PersonsHealthcare and emergency medical services personnel with direct patient contact FORMTEXT      Healthcare and emergency medical services personnel without patient contact FORMTEXT      Pregnant women  FORMTEXT      Infants and children 6 months through 3 years FORMTEXT      Children 4 years through 18 years FORMTEXT      Young adults 19 through 24 years FORMTEXT      Patients 25 through 64 years with high risk condition FORMTEXT      Patients 25-64 years FORMTEXT      65 years and older FORMTEXT      The provider may terminate this agreement at any time. The State may terminate this agreement at any time if the provider fails to comply with these requirements or if participation in the 2009 Influenza A (H1N1) monovalent vaccine vaccination effort is no longer needed. Upon termination, the provider agrees to properly return all publicly provided vaccines to the local health department. Receipt of H1N1 vaccine shall constitute acceptance of the terms of this agreement. By signing this agreement, I accept responsibility to ensure that all vaccine providers employed by, or associated with, this facility are informed of their obligations under this agreement. Return the completed enrollment form to your Local Health Department. 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