"Agreement to Participate - Hospital Tdap and Ob/Gyn Cocooning Programs" - Nevada

Agreement to Participate - Hospital Tdap and Ob/Gyn Cocooning Programs is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

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S T A T E O F N E V A D A
DIVISION OF PUBLIC & BEHAVIORAL HEALTH
Immunization Program ▪ 4150 Technology Way ▪ Suite 210 ▪ Carson City ▪ Nevada ▪ 89706
Hospital Tdap and OB/GYN Cocooning Programs
st
th
July 1
, 2017 - June 30
, 2019
AGREEMENT TO PARTICIPATE
_________________
Facility Name
NSIP Assigned PIN
Physical/Shipping Address:
Street Address (NO PO Box)
Suite
City
State
Zip
Mailing Add
ress:
(If different from shipping)
Suite
City
State
Zip
Telephone:
(
)
Fax Number:
(
)
Primary Vaccine Coordinator:
Direct Phone #: (
)
First Name
Last Name
Title
Extension:
E-mail:
Back-Up Vaccine Coordinator or Supervisor:
Direct Phone #: (
)
First Name
Last Name
Title
Extension:
Fax #:
Mailing Address (if different from
above):
Street/PO Box
Suite
City
State
Zip
E-mail:
IMPORTANT
– Days and times the clinic is open to accept delivery of vaccines:
Day Of The Week
Time Office Open for Delivery
Closed for LUNCH from/to
Time Office Closes
MONDAY:
TUESDAY:
WEDNESDAY:
THURSDAY:
FRIDAY:
Notify the Nevada State Immunization Program (in writing) of any changes, i.e. clinic closures or changes in hours of operation
July 1, 2017 - June 30, 2019 Cocooning Program Agreement to Participate-NSIP
Page 1 of 5
S T A T E O F N E V A D A
DIVISION OF PUBLIC & BEHAVIORAL HEALTH
Immunization Program ▪ 4150 Technology Way ▪ Suite 210 ▪ Carson City ▪ Nevada ▪ 89706
Hospital Tdap and OB/GYN Cocooning Programs
st
th
July 1
, 2017 - June 30
, 2019
AGREEMENT TO PARTICIPATE
_________________
Facility Name
NSIP Assigned PIN
Physical/Shipping Address:
Street Address (NO PO Box)
Suite
City
State
Zip
Mailing Add
ress:
(If different from shipping)
Suite
City
State
Zip
Telephone:
(
)
Fax Number:
(
)
Primary Vaccine Coordinator:
Direct Phone #: (
)
First Name
Last Name
Title
Extension:
E-mail:
Back-Up Vaccine Coordinator or Supervisor:
Direct Phone #: (
)
First Name
Last Name
Title
Extension:
Fax #:
Mailing Address (if different from
above):
Street/PO Box
Suite
City
State
Zip
E-mail:
IMPORTANT
– Days and times the clinic is open to accept delivery of vaccines:
Day Of The Week
Time Office Open for Delivery
Closed for LUNCH from/to
Time Office Closes
MONDAY:
TUESDAY:
WEDNESDAY:
THURSDAY:
FRIDAY:
Notify the Nevada State Immunization Program (in writing) of any changes, i.e. clinic closures or changes in hours of operation
July 1, 2017 - June 30, 2019 Cocooning Program Agreement to Participate-NSIP
Page 1 of 5
To receive publicly funded vaccines from the Nevada State Immunization Program (NSIP) at no cost I agree to
the following conditions, on behalf of myself and all the practitioners, nurses, and others associated with the
healthcare facility of which I am the medical director or practice administrator or equivalent:
Medical Director, practitioner or equivalent (one who is authorized to prescribe vaccines under Nevada State Law)
to initial all:
1) I will immunize all antepartum/postpartum mothers and one contact with state supplied Tdap vaccine at no
charge to the patient for the cost of the vaccine.
2) I will comply with immunization schedules, dosages, and contraindications that are established by the Advisory
Committee on Immunization Practices (ACIP) and included in the NSIP unless:
In the providers medical judgment, and in accordance with accepted medical practice, the provider
a)
deems such compliance to be medically inappropriate (NRS 392.439, 394.194, 432A.250);
3) I will maintain all records related to the NSIP Cocooning Program for a minimum of 3 years and make these
records available to public health officials, including the Nevada Department of Health and Human Services
and/or Federal Department of Health and Human Services, upon request.
4) For adults ages 19 years and older, the administration fee charged should not exceed the regional Medicare
vaccine administration fee of $21.34 per vaccine dose.
5) I will not deny administration of a state supplied vaccine because of the patient’s inability to pay the
administration fee.
6) I will distribute the most current Vaccine Information Statements (VIS) each time a vaccine is administered
and maintain records in accordance with the National Childhood Vaccine Injury Compensation Act (NCVIA),
which includes reporting clinically significant adverse events to the Vaccine Adverse Event Reporting
System (VAERS) (www.vaers.hhs.gov).
7) I will comply with the requirements for vaccine management and accountability including:
a) Ordering vaccine and maintaining appropriate vaccine inventory;
b) Not storing vaccine in dormitory-style units at any time;
c) Storing vaccine under proper storage conditions at all times. Refrigerator units and temperature
monitoring equipment and practices must meet Nevada State Immunization Program storage and handling
requirements;
d) Return all eligible, publicly supplied spoiled/expired vaccine to McKesson, the CDC’s centralized
distributor within six (6) months of spoilage/expiration.
_8) I will participate in NSIP compliance site visits, storage and handling unannounced visits and other education
opportunities associated with the NSIP Program requirements.
______9) I agree to use the continuous digital monitoring device provided by the NSIP to monitor vaccine storage units
containing state supplied vaccines. The NSIP will provide one (1) LogTag TRED30-7R continuous
monitoring device with capabilities of alarming for out-of-range temperatures, provides current temperatures
an minimum/maximum temperatures, low battery indicator, accuracy of +/- 1̊ F (0.5̊ C ), used in conjunction
with a detachable biosafe glycol-encased probe and come with current certificates of calibration accredited by
an ILAC MRA signatory body or meets ISO/IEC 17025 international standards. Hospitals that have storage
units monitored do not need data loggers installed as long as the system that monitors the temperatures
July 1, 2017 - June 30, 2019 Cocooning Program Agreement to Participate-NSIP
Page 2 of 5
can down load and print out monthly temperature reports to be sent to NSIP. I understand it is the
clinic’s responsibility to pay for the biennial recalibration of the data loggers. I agree to return all equipment
supplied to my office through federal or state funds to the NSIP upon termination of this agreement.
_____10) I agree to purchase at least one (1) backup thermometer with a valid and current certificate of calibration
accredited by an ILAC MRA signatory body or meets ISO/IEC 17025 international standards, capable of
alarming (visually or audibly) for out-of-range temperatures, provides current temperatures and
minimum/maximum temperatures, low battery indicator, accuracy of +/- 1°F (0.5°C), used in conjunction with
a detachable biosafe glycol-encased probe and have it readily available to ensure that twice a day temperature
assessment and recording can be performed in the event the NSIP-supplied data logger is no longer working or
has been sent for recalibration. I understand that on January 1, 2018, I will be required to purchase a
continuous temperature recording device (data logger) as my backup thermometer as required by the
CDC.
_____11) In the event the NSIP Program Manager, Vaccine Manager, Provider Quality Assurance Manager, and/or the
Vaccine Storage & Handling Coordinator recommends to my Primary Vaccine Coordinator and/or myself, the
Medical Director, that I purchase a stand-alone refrigerator as a result of reviewing long-term continuous
temperature monitoring data, and the office does not purchase the recommended storage unit type, then I
WILL BE HELD ACCOUNTABLE for replacing all state-funded vaccine doses (at private cost) on a
dose-for-dose basis that are spoiled or wasted as a result of temperature excursions in the non-
recommended unit.
12) I understand this facility or the NSIP may terminate this agreement at any time for personal reasons or failure
to comply with these requirements. If I choose to terminate this agreement, then I will notify the NSIP in
writing and properly return any unused state supplied vaccine.
_13) I will not move state supplied vaccines unless I have prior approval from the NSIP.
_14) I will record all vaccines that our office administers into Nevada’s Immunization Information System (NV
WebIZ) unless the patient has chosen to not participate. In order for a patient to opt-out of NV WebIZ, a form
must be completed and faxed or mailed to the NV WebIZ Help Desk. Providers with an undue hardship (i.e., no
internet access) can comply by completing a NV WebIZ paper reporting form and mailing to the NV WebIZ
Program. Please contact the NV WebIZ Help Desk for this form. These requirements are in reference to Nevada
Revised Statutes (NRS) 439.265 and corresponding Nevada Administrative Code (NAC) R094-09A. View these
laws at:
NRS:
http://www.leg.state.nv.us/NRS/NRS-439.html#NRS439Sec265
o
NAC:
http://www.leg.state.nv.us/NAC/NAC-439.html#NAC439Sec870
o
NV WebIZ:
http://dpbh.nv.gov/Programs/WebIZ/WebIZ - Home/
o
15) I will maintain clients’ immunization records for a period specified by NRS 629.051 “Health care records:
Retention; disclosure to patients concerning destruction of records; exceptions; regulations. #1: …Each
provider of health care shall retain the health care records of his or her patients as part of his or her regularly
maintained records for 5 years after their receipt or production. Health care records may be retained in
written form, or by microfilm or any other recognized form of size reduction, including, without limitation,
microfiche, computer disc, magnetic tape, and optical disc… Health care records may be created,
authenticated and stored in a computer system which limits access to those records. #7: A provider of health
care shall not destroy the health care records of a person who is less than 23 years of age on the date of the
proposed destruction of the records. The health care records of a person who has attained the age of 23 years
may be destroyed in accordance with this section for those records which have been retained for at least 5
years or for any longer period provided by federal law.” If requested, I will make such records available to the
Nevada Department of Health and Human Services and/or the Federal Department of Health and Human
Services. I will make such records available to the health authority and/or designee, if requested (per NAC
441A.750). This includes the collection of data for quality improvement assessments.
July 1, 2017 - June 30, 2019 Cocooning Program Agreement to Participate-NSIP
Page 3 of 5
I agree to have all staff who enter data into NV WebIZ receive the appropriate training prior to obtaining a
_____16)
username, password, entering data, or receiving vaccine (new enrollees). I also agree to have the Primary and
Back-up VFC coordinators complete either in person or online training for ordering and returning federally
funded vaccine using NV WebIZ after our clinic has been designated a Type 3 provider (e.g., managing
inventory and reconciling end of month inventory exclusively in NV WebIZ).
_____17) I agree to notify the Nevada State Immunization Program of all changes immediately as they occur including,
but not limited to:
Change of shipping/mailing address;
Change in vaccine shipping hours;
Change of Primary or Back-Up Vaccine Coordinators;
Change of telephone, fax number or contact e-mail;
Additions/deletions of physicians, PA’s and nurse practitioners to the provider site.
Explanation of each item listed above is outlined in the “July 2017-June 2019 Cocooning Programs Protocol.” T h e
Protocol can be found at:
http://dpbh.nv.gov/Programs/Cocooning/Cocooning_-_Home/
By signing this form, I certify on behalf of myself and all immunization providers in this facility that I have read and
agree to the NSIP enrollment requirements listed above and understand that I am accountable for compliance with
these requirements.
Printed Name: Medical Director, practice administrator or equivalent
Medical License #
(one who is authorized to prescribe vaccines under Nevada State Law)
Signature:
Date
July 1, 2017 - June 30, 2019 Cocooning Program Agreement to Participate-NSIP
Page 4 of 5
LIST EACH PRESCRIBING PHYSICIAN
Print the full names (including middle initial), title and licensing information of all but only those providers who possess a
medical license and prescription writing privileges who write prescriptions for the “state supplied” vaccines.
It is not necessary to include the names of all staff within this facility that may administer vaccine, but rather only those
o
who possess a medical license or are authorized to write prescriptions.
o
Hospitals need only submit information listed below on the current Physician in Chief. Entire hospital staff lists are not
required.
ALL FIELDS REQUIRED:
TITLE
MEDICAL
MIDDLE
(i.e. MD,
LICENSE
EXPIRATION
FIRST NAME
INITIAL
LAST NAME
DO, etc.)
DATE
NUMBER
(Attach another sheet if additional space is needed)
July 1, 2017 - June 30, 2019 Cocooning Program Agreement to Participate-NSIP
Page 5 of 5