|
Medicaid Data Sheet
It is not a VFC enrollment requirement to submit all providers and their NPI#. However, if you want Medicaid to pay the administration fee for VFC vaccine, AL VFC Program must submit each provider's Medicaid number, effective date, and their NPI to Medicaid.
*
Contact Name
*
Contact Phone and Area Code
*
Contact Email Address
*
VFC Clinic Name
*
VFC PIN Number
If this is a new VFC provider site, enter "New Enrollment."
*
Provider's Name
*
Title (MD, CRNP, NEP, PA, etc.)
*
Provider's NPI Number
Ten-digit number
*
Provider's Medicaid Number
*
Effective Medicaid Date
Provider's Name
Title (MD, CRNP, NEP, PA, etc.)
Provider's NPI Number
Ten-digit number
Provider's Medicaid Number
Effective Medicaid Date
Provider's Name
Title (MD, CRNP, NEP, PA, etc.)
Provider's NPI Number
Ten-digit number
Provider's Medicaid Number
Effective Medicaid Date
Provider's Name
Title (MD, CRNP, NEP, PA, etc.)
Provider's NPI Number
Ten-digit number
Provider's Medicaid Number
Effective Medicaid Date
Provider's Name
Title (MD, CRNP, NEP, PA, etc.)
Provider's NPI Number
Ten-digit number
Provider's Medicaid Number
Effective Medicaid Date
|