"Vaccine Coordinator Change Form - Immunization Program" - Nevada

Vaccine Coordinator Change Form - Immunization Program is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • Released on March 1, 2018;
  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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STATE OF NEVADA
JULIE KOTCHEVAR, Ph.D
BRIAN SANDOVAL
Governor
Administrator, DPBH
LEON RAVIN, MD
RICHARD WHITLEY, MS
Acting
Director,DHHS
Chief Medical Officer
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Immunization Program
4150 Technology Way, Suite 210
Carson City, Nevada 89706
Telephone (775) 684-5900 · Fax (775) 684-8338
VACCINE COORDINATOR CHANGE FORM
Please print
clearly
PIN Number
Effective Date
(required)
(required)
PRIMARY COORDINATOR(S) BEING REMOVED:
Remove from WebIZ for this location? (yes) (no)
BACK-UP COORDINATOR(S) BEING REMOVED:
_
Remove from WebIZ for this location? (yes) (no)
NEW PRIMARY VACCINE COORDINATOR:
Phone Number/Ext
(
)
:
Primary Vaccine
Coordinator E-mail
BACK-UP VACCINE COORDINATOR:
Phone Number/Ext
(
)
:
Back-Up E-mail
NOTE: ALL OTHER OFFICE CHANGES SHOULD BE SUBMITTED ON THE
PROVIDER INFORMATION CHANGE FORM.
For office use only:
Date Received
Date Entered in VTrckS
Vaccine Coordinator Change Form
March 2018 Revision
STATE OF NEVADA
JULIE KOTCHEVAR, Ph.D
BRIAN SANDOVAL
Governor
Administrator, DPBH
LEON RAVIN, MD
RICHARD WHITLEY, MS
Acting
Director,DHHS
Chief Medical Officer
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Immunization Program
4150 Technology Way, Suite 210
Carson City, Nevada 89706
Telephone (775) 684-5900 · Fax (775) 684-8338
VACCINE COORDINATOR CHANGE FORM
Please print
clearly
PIN Number
Effective Date
(required)
(required)
PRIMARY COORDINATOR(S) BEING REMOVED:
Remove from WebIZ for this location? (yes) (no)
BACK-UP COORDINATOR(S) BEING REMOVED:
_
Remove from WebIZ for this location? (yes) (no)
NEW PRIMARY VACCINE COORDINATOR:
Phone Number/Ext
(
)
:
Primary Vaccine
Coordinator E-mail
BACK-UP VACCINE COORDINATOR:
Phone Number/Ext
(
)
:
Back-Up E-mail
NOTE: ALL OTHER OFFICE CHANGES SHOULD BE SUBMITTED ON THE
PROVIDER INFORMATION CHANGE FORM.
For office use only:
Date Received
Date Entered in VTrckS
Vaccine Coordinator Change Form
March 2018 Revision