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

^^^^ Click Here! ^^^^

COVID-19 Vaccine Provider Process Flow Chart

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

  • Use Adobe Acrobat Reader DC, Acrobat Standard DC or Acrobat Pro DC to fill out the fillable pdf form.
  • 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
  • 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.