North Dakota 2009 Influenza A (H1N1) Monovalent Vaccine

Vaccine Provider Agreement     

A H1N1 Vaccine Provider Agreement must be completed for all providers who plan to administer H1N1 influenza vaccine. Providers who are enrolled in the Vaccines For Children Program and already receive vaccine from the NDDoH, must still complete the H1N1 Vaccine Provider Agreement.

Each site where H1N1 vaccine will be administered MUST also complete the North Dakota H1N1 Vaccination Site Registration Form.

A health system may sign for all satellite clinics. A district health unit may sign for all counties. Please communicate with the clinics that are being signed on behalf of by your site. The agreement should be shared with all vaccine providers employed by the organization/clinic. The prevention partnership provider numbers must be provided for all sites that this form is being signed on their behalf.                   

 Facility Name:               

North Dakota Prevention Partnership Provider Number (only applicable to providers who currently receive state-supplied vaccine):

North Dakota Prevention Partnership Provider Number(s) or name of clinics this site is signing on behalf of:

Address of primary facility:
Street:
           
   City:      State:      Zip:                      

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 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 immunization program prior to receipt of the vaccine.

The immunization provider agrees to:

1. Administer the 2009 Influenza A(H1N1) monovalent vaccine according to the recommendations of CDC’s Advisory Committee on Immunization Practices as adopted by the Centers for Disease Control and Prevention.
2. Store and handle the vaccine in accordance with the package insert provided with the vaccine including in compliance with cold chain requirements.
3. 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.
4. Record in the patient’s 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.
5. Report moderate and severe adverse events following vaccination to the Vaccine Adverse Event Reporting System (1-800-822-7967,  http://vaers.hhs.gov/contact.htm ) or by contacting the North Dakota Department of Health (NDDoH) at 701.328.3386 or submitting a form via the North Dakota Immunization Information System (NDIIS).

In addition, the provider:

6. 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.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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).  Immunization cards will be included in each shipment of vaccine.
12. Required to report doses administered to the North Dakota Immunization Information System (NDIIS) within seven days for all doses of 2009 Influenza A (H1N1) monovalent vaccine administered.

Receipt of H1N1 vaccine shall constitute acceptance of the terms of this agreement.

Agreed to on behalf of the above-named providers and facility(ies): 

Medical Director: 

Medical Director License #: 

Date: