Minnesota Vaccines for Children

Health Care Provider Resources

Immunization

Immunization Home

MnVFC Forms

Online ordering/vaccine order forms
Patient eligibility screening record forms
Annual/semi-annual report forms
Other MnVFC vaccine forms

Online ordering/vaccine order forms

MnVFC Online Ordering
Vaccine online ordering application.
- MnVFC Online Ordering Tip Sheet (PDF: 89KB/2 pages)
  Instructions for using the MnVFC Online Ordering application.
Pediatric Vaccine Order Form (PDF: 188KB/2 pages)
Use this form to order vaccine for patients age 18 and younger. Revised 4/12
Note: influenza and varicella vaccine are not included on this order form
Varicella Vaccine Order Form (PDF: 101KB/1 page)
Order your MnVFC varicella vaccine using this form. Revised 8/11

Minnesota Health Care Program Adults Vaccine Order Form (PDF: 42KB/2 pages)
Use this form to order vaccine for patients age 19 years and older on a Minnesota Health Care Program. Revised 3/12

Patient eligibility screening record forms

All Clinics:
May continue to use this form until July 1, 2012.
- Children 18 Years of Age or Younger (PDF: 44KB/1 page)
  Use this form to screen children 18 years of age or younger to determine MnVFC program eligibility before administering vaccine. Revised 10/10
Private Clinics:
- Children 18 Years of Age or Younger - PRIVATE (PDF: 44KB/1 page)
  MnVFC patient eligibility screening record for private clinics. Revised 4/12
- Can my child get free or low cost shots? (PDF: 63KB/1 page)
  Self-screening form for parents to see if their child is eligible for MnVFC when visiting a private clinic.
Public Clinics:
- Children 18 Years of Age or Younger - PUBLIC (PDF: 26KB/1 page)
  MnVFC patient eligibility screening record for local public health (LPH), Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), Indian Health System (IHS), and tribal clinics. Revised 5/12
- Can My Child Get Free or Low Cost Shots?
  Parents visiting local public health (LPH), Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), Indian Health System (IHS), and tribal clinics can use this self-screening form to see if their child is eligible to receive free or low cost shots from MnVFC. Available in English, Hmong, Russian, Spanish, Somali, and Vietnamese.
Adults 19 Years of Age or Older (PDF: 74KB/1 page)
Use this from to screen adults 19 years of age or older to determine Minnesota Health Program (MHCP) eligibility before administering vaccine. Revised 1/12

Annual/semi-annual report forms

Annual Provider Agreement (PDF: 157KB/3 pages)
All public and private healthcare providers seeking enrollment or continued enrollment in the MnVFC program must complete and sign this form and return to MDH by November 30 of each year. We will be unable to process vaccine orders from you after this time without it. Revised 10/11
Annual Report of the Number of Patients Immunized (PDF: 78KB/1 page)
The Annual Report (a.k.a. Annual Report Form) is an actual count of the number of eligible patients who received MDH vaccine during the previous 12 month period. Due to MDH by November 30. Revised 10/11
Semi-Annual Report of Doses Administered to Pediatric Patients - age 0 through 18 years (PDF: 305KB/1 page)
Online: Semi-Annual Report of Doses Administered to Pediatric Patients
Complete this report only if your clinic is using the replacement method of vaccine supply management. Due to MDH by May 31. Revised 11/11
Semi-Annual Report of Doses Administered to MHCP Adults - Age 19 years and older (PDF: 116KB/1 page)
Online: Semi-Annual Report of Doses Administered to MHCP Adults
Providers who administer vaccine to eligible adults (19 years and older) covered by a Minnesota Health Care Program (MHCP) should complete this report and return it to MDH by May 31. Revised 4/12

Other forms:

Returning Nonviable MDH Vaccine (PDF: 30KB/1 page)
Use this form to return nonviable (i.e., spoiled or expired) MDH vaccine to McKesson Specialty Distribution. Revised 12/11

MDH Vaccine Transfer Record (PDF: 26KB/1 page)
Form for transfering MDH vaccine to another provider in order to prevent vaccine waste. Revised 12/11
MDH Vaccine Restitution Appeal Form (PDF: 29KB/1 page)
Form to file an appeal regarding the waste of the MDH vaccine. Revised 3/11