The Minnesota Vaccines for Children (MnVFC) program is an enhanced version
of the federally funded Vaccines for Children (VFC) program. Its goal
is to ensure affordable vaccines for all children within their own clinics.
Forms |
For All
MnVFC
Clinics |
For
Public
Clinics
Only |
For
Private Clinics
Only |
| Enrollment forms: |
Annual
Provider Enrollment Agreement 2010
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 no later than December 2, 2009. We will be unable to process vaccine orders from you after this time without it. Revised
10/09 |
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Provider Profile
for Initial Enrollment in MnVFC
All public and private healthcare providers seeking initial enrollment in the MnVFC program must complete this form. Revised
9/09 |
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| Vaccine forms: |
Influenza Vaccine Order For 2009-2010
The MnVFC program will provide influenza vaccine to providers for MnVFC-eligible children ages 6 months through 18 years. Added 2/09 |
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Vaccine Order Form
Order your MnVFC vaccine using this form.
Note: influenza and varicella vaccine are not included on this order form.
Revised 10/09 |
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Adult MnVFC Vaccine Order Form
Adult MnVFC vaccine order form for 19 and older patients on a Minnesota Health Care Program. Added 10/09 |
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Varicella Vaccine Order Form - April 2008
Order your MnVFC varicella vaccine using this form.
Revised
4/24/08 |
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Returning Nonviable
MnVFC Vaccine
Use this form to return nonviable (i.e., spoiled or expired) MnVFC vaccine to McKesson Specialty Distribution. Revised 11/09 |
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MnVFC Vaccine Transfer
Record
Form for MnVFC providers to use for redistributing MnVFC vaccine
to another MnVFC provider in order to prevent waste of MnVFC
vaccine.
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| Screening forms: |
Patient Eligibility Screening Record for 2010
Children 18 Years of Age or Younger
Use this form to screen children 18 Years of Age or Younger to determine MnVFC program eligibility before administering vaccine.
Effective 10/08 |
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Patient Eligibility Screening Record
- Adults 19 Years of Age or Older
MnVFC patient eligibility screening record for adults 19 years of age or older.
Added 10/09 |
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| Report forms: |
Annual Report of the Number of MnVFC Patients Immunized (a.k.a. Annual Report Form)
The Annual Report is an actual count of the number of eligible patients who received MnVFC vaccine during the previous 12 month period. Due to MDH no later than November 30, 2009.
Revised
10/09 |
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Semi-Annual Report of Doses Administered to Adult Patients (19 years and older)
Providers who administer MnVFC vaccine to eligible adult patients age 19 and older should complete this report and return it to MDH by November 30, 2009.
Revised
10/09 |
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Semi-Annual Report of
Doses Administered to Pediatric Patients (age 0 through 18 years)
Complete this report only if your clinic is using the replacement method of vaccine supply management. Due to MDH by November 30, 2009.
Revised
10/09 |
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MnVFC Financial Restitution Appeal Form
Form to file an appeal with the MnVFC program regarding the waste of the MnVFC vaccine. Added
10/08 |
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