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2021 Vaccines for Children (VFC) Program Provider Profile Form All health care providers participating in the Vaccines for Children (VFC) program must complete this form annually or more frequently if the number of children served changes or the status of the facility changes during the calendar year. Date: ___ ___ /___ ___/ ___ ___ ___ ___ Provider Identification Number#____________________ FACILITY INFORMATION Provider’s Name: Facility Name: Vaccine Delivery Address: City: State: Zip: Telephone: Email: FACILITY TYPE (select facility type) Private Facilities Public Facilities ¨ Private Hospital ¨ Private Practice (solo/group/HMO) ¨ Private Practice (solo/groups as agent for FQHC/RHC-deputized) ¨ Community Health Center ¨ Pharmacy ¨ Birthing Hospital ¨ School-Based Clinic ¨ Teen Health Center ¨ Adolescent Only Provider ¨ Other____________________________ ¨ Public Health Department Clinic ¨ Public Health Department Clinic as agent for FQHC/RHC-deputized ¨ Public Hospital ¨ FQHC/RHC (Community/Migrant/Rural) ¨ Community Health Center ¨ Tribal/Indian Health Services Clinic ¨ Woman Infants and children ¨ Other_________________________________ ¨ STD/HIV ¨ Family Planning ¨ Juvenile Detention Center ¨ Correctional Facility ¨ Drug Treatment Facility ¨ Migrant Health Facility ¨ Refugee Health Facility ¨ School-Based Clinic ¨ Teen Health Center ¨ Adolescent Only VACCINES OFFERED (select only one box) ¨ All ACIP Recommended Vaccines for children 0 through 18 years of age. ¨ Offers Select Vaccines (This option is only available for facilities designated as Specialty Providers by the VFC 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 children ages 0-18. Local health departments and pediatricians are not considered specialty providers. The VFC Program has the authority to designate VFC providers as specialty providers. At the discretion of the VFC Program, enrolled providers such as pharmacies and mass vaccinators may offer only influenza vaccine. Select Vaccines Offered by Specialty Provider: ¡ DTaP ¡ Hepatitis A ¡ Hepatitis B ¡ HIB ¡ HPV ¡ Influenza ¡ Meningococcal Conjugate ¡ MMR ¡ Pneumococcal Conjugate ¡ Pneumococcal Polysaccharide ¡ Polio ¡ Rotavirus ¡ TD ¡ Tdap ¡ Varicella ¡ Other, specify: PROVIDER POPULATION Provider Population based on patients seen during the previous 12 months. Report the number of children who received vaccinations at your facility, by age group. Only count a child once based on the status at the last immunization visit, regardless of the number of visits made. The following table documents how many children received VFC vaccine, by category, and how many received non-VFC vaccine. VFC Vaccine Eligibility Categories # of children who received VFC Vaccine by Age Category <1 Year 1-6 Years 7-18 Years Total Enrolled in Medicaid No Health Insurance American Indian/Alaska Native Underinsured in FQHC/RHC or deputized facility1 Total VFC: Non-VFC Vaccine Eligibility Categories # of children who received non-VFC Vaccine by Age Category <1 Year 1-6 Years 7-18 Years Total Insured (private pay/health insurance covers vaccines) Children’s Health Insurance Program (CHIP)2 Total Non-VFC: Total Patients (must equal sum of Total VFC + Total Non-VFC) 1Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that are not covered by insurance. In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputized provider. The deputized provider must have a written agreement with an FQHC/RHC and the state/local/territorial immunization program in order to vaccinate these underinsured children. 2CHIP – Children enrolled in the state Children’s Health Insurance Program (CHIP). These children are considered insured and are not eligible for vaccines through the VFC program. Each state provides specific guidance on how CHIP vaccine is purchased and administered through participating providers. TYPE OF DATA USED TO DETERMINE PROVIDER POPULATION (choose all that apply) ¡ Benchmarking ¡ Medicaid Claims Data ¡ IIS ¡ Other (must describe): ¡ Doses Administered ¡ Provider Encounter Data ¡ Billing System