Provider Enrollment

Each year, a completed provider agreement is required prior to the receipt of publicly supplied vaccine. More information can be found in the Adult Vaccine Program User Manual

Provider Agreement Instructions (PDF)
This guide provides instructions for how to complete the Adult Vaccine Program Provider Agreement. Please review all instructions before filling out the agreement. 

Provider Agreement (Adobe Sign Form)
The Adult Vaccine Program Provider Agreement is an Adobe Sign form. The primary vaccine coordinator will need to have all documentation ready before filling out the form because it cannot be saved once started. The provider agreement must be electronically signed by the primary vaccine coordinator and medical director.

Provider agreements that are printed and filled out by hand will not be accepted.

If you have any questions, please email