Become a COVID-19 Vaccine Provider

Want to become a COVID-19 Vaccine Provider?

If you are a Healthcare facility or Primary Care Physician who would like to administer COVID-19 vaccines to your patients, please complete the COVID-19 Provider Survey Form.

Interested providers who complete the survey form, will receive an email from the Department of Health’s Immunization Registry that will include three (3) attachments:

  1. CDC COVID-19 Vaccination Program Provider Agreement – a fillable pdf form
  2. General Instructions and Tips
  3. Creating Your Digital Signature-ID Instructions

COVID-19 Vaccine Provider Process Flow Chart

What information do I need to complete the CDC COVID-19 Vaccination Program Agreement form?

  1. Use Adobe Acrobat Reader DC, Acrobat Standard DC or Acrobat Pro DC to fill out the fillable pdf form.
  2. Gather Information to complete various sections of the form

Section A

  • CMO and CEO: Name, Telephone, Email address
  • Medical Director and CEO digital signatures required

Section B

  • Primary Vaccine Coordinator: Name, Telephone, Email address
  • Backup Vaccine Coordinator: Name, Telephone, Email address
  • Location address for vaccine shipments
  • Location address where vaccine will be administered
  • Days/times for receipt of vaccine shipments
  • Approximate number of patients served by location
  • Storage unit details (brand/model/type)
  • List of licensed providers who will be handling COVID-19 vaccine
  • Provider Name, Title, License No.

Onboard now. Plan for it to take time.

What are CDC’s requirements for becoming a COVID-19 vaccination provider?

To become a COVID-19 vaccination provider:

  • You must be licensed to administer vaccines in the jurisdiction where you practice
  • You are required to sign and abide by the terms of the CDC COVID-19 Vaccination Program Provider Agreement.
  • You follow best practices for storing, handling, and administering vaccine

Refer to CDC’s U.S. COVID-19 Vaccine Product Information) and the Vaccine Storage and Handling Toolkit

  • You report vaccine administration and vaccine adverse events

Who to contact for assistance?

  • Email [email protected]
  • Call 808-586-8360. Provide your contact details, someone will get back to you.