New Jersey Department of Health

Vaccines for Children (NJVFC) Program

PO Box 369

Trenton, NJ 08625-0369

Phone: 609-826-4862 Fax: 609-826-4868

PROVIDER DISENROLLMENT REQUEST	Medicaid ID No. (Mandatory)

PIN Number

Tax ID Number

NPI Number

Instructions: Email this form to the NJVFC Program at VFC@doh.nj.gov, 2 months BEFORE the date of your disenrollment. A NJVFC Program Representative will contact you regarding the disposition of NJVFC vaccine.

Site Name

Date

Street Address

City

Zip Code

Name of Contact Person

Telephone Number

( )	Fax Number

( )
Reason for Disenrollment

Closing Office No longer seeing VFC-eligible children	Effective Date

Other (specify):
Vaccine

(Specify Type,

e.g., DTaP, etc.)	Vaccine Inventory	Disposition Transaction Code

(See below)
Number of Doses on Hand

(VFC Only)	Manufacturer	Lot Number	Expiration

Date
Additional Information:

NJVFC MUST be called to obtain permission for vaccine transfer.

Transfer Approved by:	to PIN Number:
Note: You are responsible for the VFC vaccine you have received. Therefore, you will need to account for any missing doses of NJVFC vaccines by entering vaccinations into NJIIS, providing copies of Eligibility/Vaccine Encounter screening forms or replacing the missing NJVFC vaccines.

Transaction Codes (Enter one of these codes into the column above. Provide additional information as required.

1 - Viable Vaccine / Transferred to Another NJVFC Provider.

2 - Expired or Wasted Vaccine / Returned to NJVFC Program

Signature	Date

IMM-30

APR 16

IMM-30, Vaccines for Children Program, Provider Disenrollment Request

IMM-30, immunization, NJ VFC, vaccine preventable diseases, provider enrollment, COMMUNICABLE DISEASE SERVICE, IMMUNIZATION

Elaine White

2005-01-19

ewhite

NJDOH