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To: Maine Immunization Providers
From: Maine Immunization Program
Subject: 2018 Maine Immunization Program
Provider Vaccine Agreement
Date: December 6, 2017
Providers enrolled
in the Maine Immunization Program are required to submit an annual Provider Agreement. The Provider Agreement is now available in ImmPact. Providers who have not submitted a 2018 Provider
Agreement prior to December
31, 2017 will be suspended from ordering vaccines until an agreement
has been submitted and approved. Sites participating in an interface should also be aware that as of January 1, 2018 administered doses
will not decrement from inventory until the
2018 Provider Agreement
is in an approved status.
To fill out and submit your Provider
Agreement, Log in to ImmPact and please do the following:
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Click Manage Sites: Verify and update
any
information as this will be used to populate the Provider Agreement
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Click Manage Clinicians: Update your Clinicians, as needed
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Click Manage
Providers: Update your Providers, as needed. ALL PROVIDERS MUST HAVE A MEDICAL
LICENSE NUMBER and NATIONAL PROVIDER IDENTIFCATION (NPI) NUMBER
- Click Provider Agreement
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Click on “Create New 2018 Agreement”
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Complete the Site Profile on Page 1
- Complete Patient Enrollment Estimates,
DO NOT LEAVE BLANK, 2017 previous enrollmentnumbers are available to use as a reference
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Review Clinicians and Physicians/Providers List to verify information is correct
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Complete Emergency Storage and Handling Protocol
- detail how you will be contacted if a power outage occurs for example,
security company or someone lives in the area etc.
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Complete Signature Pages, Acknowledgements and Submit
5. Once your agreement is submitted through ImmPact, Click Provider Agreement, Click PDF Signature and print these pages
6. Have the appropriate person(s) sign next to their typed name
7. Please fax your PDF Signature Pages to (207-287-8127 or 1-800-437-5743)
8. Print the full PDF for your records
Thank you for your dedication to keep the citizens of Maine
free from vaccine-preventable diseases.
If you have any questions, please contact the Maine Immunization Program at:
Phone (207) 287-3746
or (800) 867-4775,
Email: ImmunizeME.DHHS@Maine.gov
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