Provider Profile                                        
Vaccines for Children Program

1.  Today’s Date:  _ _ _ _   _ _   _ _ 			2. Employer Identification Number: __________________
               	   	   M  M   D   D   Y  Y   Y   Y	

All state or project approved public and private health care providers participating in the Vaccines for Children program (VFC) must complete this form.  This document provides shipping information and helps the state determine the amount of vaccine to be supplied through the VFC program.  This form  may also be used to compare estimated vaccine needs with actual vaccine supply.  The state health department must keep this record on file with the “Provider Enrollment” form.  The Provider Profile form must be updated annually or more frequently if 1) the number of children being served changes, or 2) the status of the facility changes.  One provider may complete the form for the entire practice.

3.  Provider’s Name: ________________________________________________________________________ 

4.  Clinic Name: ____________________________________________________________________________

5.  Vaccine Delivery Address: 	_______________________________________________________________
  	  Street (No P.O. Boxes)
     				_________________________		____________		___________  
     				 City					  State		  	   Zip Code

6.  Telephone Number: (      )   ________________________	7.  Fax Number: (      )   __________________

7.   E-mail: ________________________________________
	
8.	Type of Facility: 

               □   A.  Public Health Department				□    B.  Public Hospital
                  □  C.  Private Practice (Individual or Group)		□    D.  Private Hospital
                  □  E.  Federally Qualified Health Center (FQHC)		□    F.  Rural Health Clinic (RHC)
                  □  G.  Other Public Facility ______________		□    H.  Other Private Facility_________________
        (Specify)						         (Specify)

Provider Estimates:

Part A.	For the 12 mo. period beginning  __ __ __ __ __ __        Report the number of children who will receive 
                                                                            M     M   D   D    Y   Y              vaccinations at your health facility, by age group.  Only                                                                                                                 count a child once in each 12 month period no matter the                                                                                                             number of visits.
<1 Y ear Old | 1-6 Years | 7-18 Years | Total
a. | b. | c. | d.

Part B.	Of the total number for each age group entered above, how many children are expected to be VFC eligible, by category?
| <1 Year | 1-6 Years | 7-18 Years | Total
Enrolled in Medicaid | | | |
No health insurance | | | |
American Indian/Alaska Native | | | |
Underinsured* | | | |
Total (Note:  Totals should equal totals under 8 Part A:  A-C) | a. | b. | c. | d.

* To be VFC-eligible, underinsured children must be vaccinated through a FQHC or RHC.  

Type of data used to determine profile:
    □  A.  Benchmarking				□   B.  Medicaid Claims Data
    □  C.  Dose Administered			□  D.  Provider Encounter Data
   □  E.  Registry					□   F.  Other ____________________________
(specify)