ࡱ> q  gbjbjt+t+ pAAdC]<<<<<<<D$$d2 (|21111111$35)1<)1 << <<1<<<<1 r *u0|<<1 d+"0New Jersey Department of Health Vaccines for Children (NJVFC) Program P.O. Box 369 Trenton, NJ 08625-0369 Phone: (609) 826-4862 Fax: (609) 826-4868 INSTRUCTIONS: Email completed New Provider Enrollment for Adult Site and New Provider Agreement for Adult Site to: VFC@doh.nj.gov.NEW PROVIDER ENROLLMENT FOR ADULT SITETodays Date (MM/DD/YYYY)  FORMTEXT __ __ / __ __ / __ __ __ __PROVIDER INFORMATIONOffice Name:  FORMTEXT      Office Medicaid Number: FORMTEXT      Office NPI Number: FORMTEXT      Office Tax ID: FORMTEXT      Provider Type:Private Facilities:  FORMCHECKBOX  Not for Profit Clinic (Proof of not for profit status must be sent with this enrollment.) Public Facilities:  FORMCHECKBOX  Public Health Department  FORMCHECKBOX  Federally Qualified Health CenterVaccines Offered (Select only one box): FORMCHECKBOX  All ACIP Recommended Vaccines for Adults  FORMCHECKBOX  Offers Select Vaccines (This option is only available for facilities designated as Specialty Providers by the 317 Program.)A Specialty Provider is defined as a provider that only serves (1) a defined population due to the practice specialty (e.g., OB/GYN, STD clinic, family planning) or (2) a specific age group within the general population of adults ages 19+. Local health departments are not considered specialty providers. The 317 Program has the authority to designate 317 providers as specialty providers.Select Vaccines Offered by Specialty Provider: FORMCHECKBOX  Hepatitis A/B  FORMCHECKBOX  Meningococcal Conjugate  FORMCHECKBOX  TD FORMCHECKBOX  HPV  FORMCHECKBOX  MMR  FORMCHECKBOX  Tdap FORMCHECKBOX  Influenza  FORMCHECKBOX  Pneumococcal Conjugate  FORMCHECKBOX  Varicella FORMCHECKBOX  Men B  FORMCHECKBOX  Pneumococcal Polysaccharide  FORMCHECKBOX  Zoster FORMCHECKBOX  Other (specify): FORMTEXT      Vaccine Delivery AddressAddress 1: FORMTEXT      Address 2: FORMTEXT      City: FORMTEXT      State:NJZip: FORMTEXT      County: FORMTEXT      Municipality: FORMTEXT      Phone:( FORMTEXT      )  FORMTEXT      Ext. FORMTEXT      Fax:( FORMTEXT      )  FORMTEXT      Email: FORMTEXT      LICENSED MEDICAL PROVIDERS The Medical Director signing this agreement must be authorized to administer adult vaccines under state law. The Medical Director will be held accountable for 317-Funded Adult Program compliance by the entire organization with all items stated in the Provider Agreement for adult sites. 1. Medical DirectorTitle: FORMCHECKBOX  MD  FORMCHECKBOX  DODate of Birth: FORMTEXT      Last Name: FORMTEXT      First Name: FORMTEXT      Middle Name: FORMTEXT      NPI No.: FORMTEXT      Medical License No.: FORMTEXT      Medicaid No.: FORMTEXT      2. Licensed Medical ProviderTitle: FORMCHECKBOX  MD  FORMCHECKBOX  DO  FORMCHECKBOX  PA  FORMCHECKBOX  NPDate of Birth: FORMTEXT      Last Name: FORMTEXT      First Name: FORMTEXT      Middle Name: FORMTEXT      NPI No.: FORMTEXT      Medical License No.: FORMTEXT      Medicaid No.: FORMTEXT      LICENSED MEDICAL PROVIDERS, CONTINUED3. Licensed Medical ProviderTitle: FORMCHECKBOX  MD  FORMCHECKBOX  DO  FORMCHECKBOX  PA  FORMCHECKBOX  NPDate of Birth: FORMTEXT      Last Name: FORMTEXT      First Name: FORMTEXT      Middle Name: FORMTEXT      NPI No.: FORMTEXT      Medical License No.: FORMTEXT      Medicaid No.: FORMTEXT      4. Licensed Medical ProviderTitle: FORMCHECKBOX  MD  FORMCHECKBOX  DO  FORMCHECKBOX  PA  FORMCHECKBOX  NPDate of Birth: FORMTEXT      Last Name: FORMTEXT      First Name: FORMTEXT      Middle Name: FORMTEXT      NPI No.: FORMTEXT      Medical License No.: FORMTEXT      Medicaid No.: FORMTEXT      ASSOCIATED ADDITIONAL MEDICAL OFFICES (Complete this section only if there are other offices in the practice. If none, go to next section.)1. Medical Office Name: FORMTEXT      VFC Pin: FORMTEXT      Street 1: FORMTEXT      Street 2: FORMTEXT      City: FORMTEXT      State:NJZip: FORMTEXT      County: FORMTEXT      Municipality: FORMTEXT      Phone:( FORMTEXT      )  FORMTEXT      Ext. FORMTEXT      Fax:( FORMTEXT      )  FORMTEXT      2. Medical Office Name: FORMTEXT      VFC Pin: FORMTEXT      Street 1: FORMTEXT      Street 2: FORMTEXT      City: FORMTEXT      State:NJZip: FORMTEXT      County: FORMTEXT      Municipality: FORMTEXT      Phone:( FORMTEXT      )  FORMTEXT      Ext. FORMTEXT      Fax:( FORMTEXT      )  FORMTEXT      ADULT SITE CONTACTS Two designated on-site and fully trained staff responsible for all vaccine management activities within the practice.Primary Vaccine Coordinator:Last Name: FORMTEXT      First Name: FORMTEXT      Middle Name: FORMTEXT      Email: FORMTEXT      Phone: FORMTEXT      Ext. FORMTEXT      Backup Vaccine Coordinator:Last Name: FORMTEXT      First Name: FORMTEXT      Middle Name: FORMTEXT      Email: FORMTEXT      Phone: FORMTEXT      Ext. FORMTEXT      VACCINE DELIVERY HOURS (Hours when vaccine shipments can be delivered. Exclude lunch hours if office is closed. Note: No deliveries are made on Mondays.) FORMCHECKBOX  Tuesday  FORMCHECKBOX  Wednesday  FORMCHECKBOX  Thursday  FORMCHECKBOX  FridayFrom (hh:mm):  FORMTEXT   : FORMTEXT   To (hh:mm): FORMTEXT   : FORMTEXT   ANDFrom (hh:mm):  FORMTEXT   : FORMTEXT   To (hh:mm): FORMTEXT   : FORMTEXT    FORMCHECKBOX  Tuesday  FORMCHECKBOX  Wednesday  FORMCHECKBOX  Thursday  FORMCHECKBOX  FridayFrom (hh:mm):  FORMTEXT   : FORMTEXT   To (hh:mm): FORMTEXT   : FORMTEXT   ANDFrom (hh:mm):  FORMTEXT   : FORMTEXT   To (hh:mm): FORMTEXT   : FORMTEXT    FORMCHECKBOX  Tuesday  FORMCHECKBOX  Wednesday  FORMCHECKBOX  Thursday  FORMCHECKBOX  FridayFrom (hh:mm):  FORMTEXT   : FORMTEXT   To (hh:mm): FORMTEXT   : FORMTEXT   ANDFrom (hh:mm):  FORMTEXT   : FORMTEXT   To (hh:mm): FORMTEXT   : FORMTEXT   Special Delivery Instructions: FORMTEXT      NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY (NIST) THERMOMETERS (Enter only one Certification Number for dual probe thermometer Certificates.)Thermometers:1. Type: FORMCHECKBOX  Data Logger  FORMCHECKBOX  Digital Min/Max ThermometerCertification or Serial Number: FORMTEXT      NIST Certification Expiration Date: FORMTEXT      2. Type: FORMCHECKBOX  Data Logger  FORMCHECKBOX  Digital Min/Max ThermometerCertification or Serial Number: FORMTEXT      NIST Certification Expiration Date: FORMTEXT      3. Type: FORMCHECKBOX  Data Logger  FORMCHECKBOX  Digital Min/Max ThermometerCertification or Serial Number: FORMTEXT      NIST Certification Expiration Date: FORMTEXT      4. Type: FORMCHECKBOX  Data Logger  FORMCHECKBOX  Digital Min/Max ThermometerCertification or Serial Number: FORMTEXT      NIST Certification Expiration Date: FORMTEXT      Back-Up Thermometer (Required):1. Type: FORMCHECKBOX  Data Logger  FORMCHECKBOX  Digital Min/Max ThermometerCertification or Serial Number: FORMTEXT      NIST Certification Expiration Date: FORMTEXT      PROVIDER POPULATION:Provider population based on patients seen during the previous 12 months. Report the number of adults who received vaccinations at your facility, by age group. Only count an adult once based on the status at the last immunization visit, regardless of the number of visits made. The following table documents how many adults received 317-funded vaccine, by category, and how many received non-317 vaccine.Number of Adults Who Received Vaccine by Age Category317 Vaccine Eligibility Categories19-29 years old30-39 years old40-59 years old60+ years oldNo Health Insurance FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Underinsured 1 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Non-317 Vaccine Eligibility Category19-29 years old30-39 years old40-59 years old60+ years oldHealth Insurance Pays Some/All Vaccine Cost FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      1 Underinsured includes adults with health insurance that does not include vaccines or only covers specific vaccine types. Adults are only eligible for vaccines that are not covered by insurance.TYPE OF DATA USED TO DETERMINE PROVIDER POPULATION (Choose ALL that apply): FORMCHECKBOX  Benchmarking  FORMCHECKBOX  Doses Administered FORMCHECKBOX  Medicaid Claims Data  FORMCHECKBOX  Provider Encounter Data FORMCHECKBOX  NJIIS  FORMCHECKBOX  Billing System FORMCHECKBOX  Other (must describe): FORMTEXT      The Medical Director signing this agreement must be authorized to administer adult vaccines under state law. The Medical Director will be held accountable for 317-Funded Adult Program compliance by the entire organization with all items stated in the Provider Agreement for adult sites. Print Name of Medical Director:Signature of Medical Director:Date:FOR STATE USE ONLYDate Certified for NJVFCStaff NamePIN NumberFederal HHS OIG Search Done FORMCHECKBOX  Yes  FORMCHECKBOX  NoNJ Consumer Affairs OIG Search Done FORMCHECKBOX  Yes  FORMCHECKBOX  NoAddress Checked on USPS Site FORMCHECKBOX  Yes  FORMCHECKBOX  NoCorrection made toconform to USPS Address FORMCHECKBOX  Yes  FORMCHECKBOX  NoChecked Not forProfit Status FORMCHECKBOX  Yes  FORMCHECKBOX  NoDocument clarification of HHS OIG an NJ Division of Consumer Affairs issues here: New Jersey Department of Health Vaccines for Children (NJVFC) Program PO Box 369 Trenton, NJ 08625-0369 Phone: (609) 826-4862 Fax: (609) 826-4868NEW PROVIDER AGREEMENT FOR ADULT SITESInstructions: Email the completed VFC New Provider Agreement for Adult Sites and the New Provider Enrollment for Adult Sites to: VFC@doh.nj.gov. Office Name  FORMTEXT      Office Medicaid Number  FORMTEXT       PROVIDER AGREEMENT To receive publicly funded vaccines at no cost, I agree to the following conditions on behalf of myself and all the practitioners, nurses and others associated with the healthcare facility of which I am the medical director or equivalent: 1. I will annually submit a provider profile representing populations served by my practice/facility. I will submit more frequently if (1) the number of adults served changes or (2) the status of the facility changes during the calendar year. 2. I will screen patients and document eligibility status at each immunization encounter for 317-Funded Adult (317) Program eligibility and administer 317-purchased vaccine by such category only to adults who are 19 years of age or older who meet one or more of the following categories: A. 317 vaccine-eligible adults: (1) have no health insurance (2) have health insurance that covers no part of the vaccine. B. fully insured individuals seeking vaccines during identified public health response activities* including: (1) outbreak response (2) post-exposure prophylaxis (3) disaster relief efforts (4) mass vaccination campaigns or exercises for public health preparedness. * Pre-approval must be obtained from the NJVFC Program prior to the use of 317-Funded vaccine for the above activities. Individuals that do not meet one or more of the above eligibility categories are NOT eligible to receive 317-purchased vaccine. Note: Adults whose health insurance covers any portion of the cost of vaccine are not eligible for 317-purchased vaccines. This applies even when a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier because the plans deductible or co-pay had not been met. 3. For the vaccines identified and agreed upon in the provider profile, I will comply with immunization schedules, dosages, and contraindications that are established by the Advisory Committee on Immunization Practices (ACIP) and included in the 317-Funded Adult Program unless: A. In the providers medical judgement, and in accordance with accepted medical practice, the provider deems such compliance to be medically inappropriate for the adult. B. The particular requirements contradict state law, including laws pertaining to religious or other exemptions. 4. I will maintain all records related to the 317 Program for a minimum of three years and, upon request, make these records available for review. 317 records include, but are not limited to, screening and eligibility documentation, billing records, medical records that verify receipt of vaccine, vaccine ordering records, and vaccine purchase and accountability records. 5. I will immunize eligible adults with publicly-supplied vaccine at no charge to the patient for the vaccine. 6. I will not charge a vaccine administration fee to 317-eligible adults that exceeds the administration fee cap of $24.23 per vaccine dose. 7. I will not deny administration of a publicly-purchased vaccine to an established patient because the individual is unable to pay the administration fee. 8. I will distribute the current Vaccine Information Statements (VIS) each time a vaccine is administered and maintain records in accordance with the National Childhood Vaccine Injury Act (NCVIA), which includes reporting clinically significant adverse events to the Vaccine Adverse Event Reporting System (VAERS). 9. I will comply with the requirements for vaccine management, including: A. Ordering vaccine and maintaining appropriate vaccine inventories. B. Not storing vaccine in dormitory-style units at any time. C. Storing vaccine under proper storage conditions at all time. Refrigerator and freezer vaccine storage units and temperature monitoring equipment and practices must meet the New Jersey Vaccines for Children Program (NJVFC) storage and handling requirements. D. Returning all spoiled/expired public vaccines to CDCs centralized vaccine distributor within six months of spoilage/expiration. 10. I agree to operate within the 317 Program in a manner intended to avoid fraud and abuse. Consistent with fraud and abuse as defined in the Medicaid regulations at 42 CFR 455.2, and for the purposes of the 317 Program: Fraud: is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law. Abuse: provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Medicaid program (and/or including actions that result in an unnecessary cost to the immunization program, a health insurance company, or a patient); or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. 11. I will participate in 317 Program compliance site visits, including unannounced visits, and other educational opportunities associated with 317 Program requirements. 12. I agree to replace vaccine purchased with federal funds (317) that are deemed non-viable due to provider negligence on a dose-for-dose basis. 13. Per N.J.A.C. 8:57-3.16, I understand that all providers administering vaccines to children less than 7 years of age must register as a provider with the New Jersey Immunization Information System (NJIIS) and report vaccinations online within 30 days. Additionally, I understand that the 317 Program requires every provider to enter all vaccinations given with 317-funded vaccine, into NJIIS within 30 days of administration (regardless of the age of the patient) and agree to comply with this mandate. 14. I understand this facility or the New Jersey Vaccines for Children Program which manages the 317-Funded Adult Program, may terminate this agreement at any time. If I choose to terminate this agreement, I will properly return any unused federal vaccine as directed by the 317 Program. By signing below, I acknowledge that I have read and accept the Provider Agreement. Print Name of Medical Director: FORMTEXT      Signature of Medical Director:Date: NEW PROVIDER ENROLLMENT FOR ADULT SITE (Continued) IMM-18 JUL 16 Page  PAGE 4of 4 Pages. IMM-18 JUL 16 Page  PAGE 1of 4 Pages. 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