Date:  January 22, 2020  
 Introduction/Instructions

Your interest in participating in the Louisiana Vaccinees for Children Re-Enrollment 2016 vaccination effort is greatly appreciated as a vital service that will protect individuals and the public against Vaccines. To ensure that you are prepared to meet the requirements for participating in this effort, you will need to complete a multi-step enrollment process. All signature forms must be signed by a provider who is licensed in the state of Louisiana to prescribe vaccines and is responsible for making decisions about the clinic and its operations.

Completing the enrollment forms could take 15 to 20 minutes. You will need the following information available to complete the forms.

  • Facility details - physical address, vaccine delivery address, and mailing address (if different)
  • Contact details - names, email addresses, telephone and fax numbers.
  • Shipping details - days and times available to receive vaccine shipments.
  • Physician/Vaccinator details - name, designation, Louisiana State Medical License Number, and National Provider ID for each physician/vaccinator in your practice.
  • Certified thermometer details.
  • Estimated number of patients to be vaccinated.

Step 1 - Pre-Registration Checklist
            You must be able to answer "Yes" to each question to proceed to the next step.

Step 2 - Provider Agreement - for receipt of publicly supplied vaccine
            You must complete all required fields in each section of the form to proceed to the next step.
            You will need to print, sign, and fax/mail the signature page of the agreement to the State of Louisiana Immunization Program.
            You should print a complete copy of the agreement for your records.

Please click the Continue button to begin or click the Print button to print these instructions.

If you have questions regarding the enrollment process or any of the following forms, please contact the State of Louisiana Immunization Program at (504)838-5300.