The Provider Enrollment page can be accessed by clicking the 'provider agreement' from the Vfc Re-Enrollment left navigation menu and then clicking 'Next' in Provider Agreement Page. The Provider Enrollment page captures the organization and organization contact details.
The below sections are used to capture the facility and contact information.
This section allows changing the Facility name, county, phone, fax and e-mail of your organization.
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Field Name
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Description
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Facility Name
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Required Field. Name of the facility. Pre-populated with the existing facility name.
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VFC PIN
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Required Field. VFC PIN number of the facility. This is a read only field. Pre-populated with existing VFC PIN.
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County
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The county where the facility is located. Drop down lists all Idaho counties. Pre-populated with existing county if available.
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Telephone
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Required Field. Primary phone number of the facility. Pre-populated with existing Phone if available.
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Facsimile
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Required Field. Primary fax number of the facility. Pre-populated with existing Facsimile if available.
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EMail
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Primary e-mail of the facility. Pre-populated with existing e-mail if available.
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Facility Address Information
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The facility is required to have three addresses namely Physical, Mailing, and Vaccine Delivery. A facility can have a Mailing and Vaccine Delivery addresses which are different from the Physical Address. All three addresses have the same fields except that the vaccine delivery address will not have a PO BOX.
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Field Name
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Description
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Address 1
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Required Field. Address Line 1. Pre-populated with existing address 1 if available.
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Address 2
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Address Line 2. Pre-populated with existing address 2 if available.
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PO BOX
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Address PO BOX. Pre-populated with existing PO BOX if available.
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City
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Required Field. Address City. Pre-populated with existing City if available.
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State
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Required Field. Drop down to select State. Pre-populated with existing State if available.
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Zip
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Required Field. 5 digit Zip code. Pre-populated with existing Zip if available.
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+4
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4 digit Zip extension. Pre-populated with existing Zip extension if available.
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Note: The check box "Populate with Physical Address" is available for Mailing and Vaccine Delivery Addresses which enables copying the Physical Address to Mailing and Vaccine Delivery Addresses as needed.
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This sections captures the individual contacts such as Medical Director or Equivalent, Primary Vaccine Coordinator, and Backup Vaccine Coordinator.
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Medical Director or Equivalent:
The Medical Director or Equivalent section captures the contact details of the Medical Director or Equivalent for the facility. Below are the available fields.
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Field Name
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Description
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Last Name
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Required Field. Last Name of the Contact. Pre-populated with existing contact details if available.
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First Name
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Required Field. First Name of the Contact. Pre-populated with existing contact details if available.
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Middle Name
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Middle Name of the Contact. Pre-populated with existing contact details if available.
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Title
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Required Field. Title of the contact. Pre-populated with existing contact details if available.
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Specialty
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Specialty of the contact. Pre-populated with existing contact details if available.
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Medical License Number
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Required Field. Medical License number of the contact. Pre-populated with existing contact details if available.
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Medicaid/NPI Number
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Required Field. Medicaid/NPI number of the contact. Pre-populated with existing contact details if available.
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Employee Identification Number
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Employee Identification Number of the contact. Pre-populated with existing contact details if available.
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EMail
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Required Field. E-Mail of the contact. Pre-populated with existing contact details if available.
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VFC Vaccine Coordinators:
The VFC Vaccine Coordinators section captures the contact details of Primary and Backup Vaccine Coordinators as well as the annual trainings they have taken.
Contact Fields:
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Field Name
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Description
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Last Name
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Required Field. Last Name of the Contact. Pre-populated with existing contact details if available.
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First Name
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Required Field. First Name of the Contact. Pre-populated with existing contact details if available.
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Middle Name
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Middle Name of the Contact. Pre-populated with existing contact details if available.
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Telephone
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Phone number of the contact. Pre-populated with existing contact details if available.
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EMail
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Required Field. E-Mail of the contact. Pre-populated with existing contact details if available.
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Annual Trainings:
At least one of the listed annual trainings or N/A - Did not complete training must be selected for each of the vaccine coordinators.
Note: The training selections made during the previous year's VFC re-enrollment will be cleared out to make sure that the annual trainings are selected for the current enrollment.
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Trainings
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Participated in an Enrollment visit.
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Participated in a Vaccines for Children (VFC) visit.
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Participated in an Educational visit conducted by local health district staff.
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Completed the CDC's "You Call the Shots" Vaccines for Children AND Vaccine Storage & Handling online modules.
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N/A - Did not complete training
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The Policies and Guidelines section provides a check box to ensure that the Medical Director or Equivalent and the VFC Vaccine Coordinators read the current Idaho Immunization Program (IIP) Provider Policies and Guidelines and comply with it. The current Idaho Immunization Program (IIP) Provider Policies and Guidelines can be viewed by clicking the link provided in this section.
Note: The Policies and Guidelines check box will be cleared out to make sure that the Policies and Guidelines are read and accepted for the current enrollment.
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Providers Practicing at this Facility
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The Providers Practicing at this Facility section captures the contact details for all the providers practicing at the facility. Below are the available fields and buttons in this section. The existing list of Providers Practicing at this Facility will be listed at the end of the input fields.
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Field Name
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Description
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Last Name
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Required Field. Last Name of the Contact.
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First Name
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Required Field. First Name of the Contact.
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Middle Name
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Middle Name of the Contact.
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Medical License Number
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Required Field. Medical License number of the contact.
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Title
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Required Field. Title of the contact.
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Medicaid/NPI Number
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Required Field. Medicaid/NPI number of the contact.
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EIN
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Employee Identification Number of the contact.
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When 'Add' button is clicked after entering the contact details for a provider practicing at the facility, the contact will be added to the list of providers practicing at the facility
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When 'Delete' button is clicked against a provider practicing at the facility, the contact will be deleted.
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Button
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Description
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When Save is clicked, all fields are validated. If there are errors, the error message are displayed and the form is not saved and when there are no errors, the provider agreement is saved.
- If information is saved while not in Enrollment Period and the provider VFC Status is Active (i.e. provider is changing information but not re-enrolling), the Next button will be enabled but the Submit button will not be displayed. The message 'Saved successfully and submitted to the Idaho Immunization Program' will be displayed. An e-mail notification will be sent IIP with list of changes made since the last save of Provider Agreement.
- If information is saved during Enrollment Period and Organization’s VFC Status is Active, Pending or Suspended OR if outside the enrollment period and the Organization’s VFC Status is Pending or Suspended (i.e. provider is re-enrolling) and if the user has not saved the Provider Agreement, Provider Profile and Brand Choice after the current Enrollment Period has started, the message 'The re-enrollment is not complete. Please review and save the Provider Agreement, Provider Profile, and Brand Choice. Once all three forms have been saved, the information must be submitted to the medical director or equivalent for signature.' will be displayed at the end of the page. The Submit button will not be displayed and the Next button will be enabled.
- If information is saved during Enrollment Period and Organization’s VFC Status is Active, Pending or Suspended OR if outside the enrollment period and the Organization’s VFC Status is Pending or Suspended (i.e. provider is re-enrolling) and if the user has saved the Provider Agreement, Provider Profile and Brand Choice after the current Enrollment Period has started, the message 'Provider Agreement, Provider Profile and Brand Choice have all been saved successfully for VFC Re-enrollment. Click Submit to notify the medical director the forms are ready for review and signature.' will display at the end of the page. The Submit button will be displayed and the Next button will be enabled.
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The Submit button will be visible only when if information is saved during Enrollment Period and Organization’s VFC Status is Active, Pending or Suspended OR if outside the enrollment period and the Organization’s VFC Status is Pending or Suspended (i.e. provider is re-enrolling) and if the user has saved the Provider Agreement, Provider Profile and Brand Choice after the current Enrollment Period has started.
When Submit is clicked, all fields are validated. If there are errors, the error message are displayed and the form is not saved and when there are no errors, the provider agreement is saved and the message 'Submitted to your Medical Director for review and signature.' is displayed. An e-mail notification will be sent to Medical Director or Equivalent notifying that the VFC Re-enrollment form is submitted for review and sign.
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The Print will be enabled after the page is saved. When Print is clicked, the Provider Agreement form (Provider Agreement, Facility Information, Medical Director Information, Primary Vaccine Coordinator, Backup Vaccine Coordinator and Providers Practicing at this facility.) is printed as a PDF file.
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The Next will be enabled after the page is saved. When Next is clicked, the user will be taken from the Provider Agreement page to the Provider Profile page.
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When Cancel is clicked, any changes that have been made since the last Save, will be cancelled.
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