COVID-19 Vaccine Providers
In anticipation of the availability of a safe and effective vaccine as early as October 2020, the Pennsylvania Department of Health will be sending a more formal invitation in the coming days and weeks for you to consider enrolling as a COVID-19 vaccine provider. We will be welcoming existing partners who may already be a part of Pennsylvania's Immunizations Program (i.e. Vaccines for Children) as well as new partners, both of whom will be essential to the success of Pennsylvania's COVID-19 Vaccination Program. Please note that our plan for vaccine distribution includes a three-phased structure to correspond with the expected availability of doses. Therefore, we may be taking a targeted approach to COVID-19 Vaccination Provider enrollment. For example, in Phase 1, there may be a limited number of doses available, so we will allocate those to providers who will be able to reach critical populations at highest risk.
In all cases, to receive and administer COVID-19 vaccine, providers must be credentialed/licensed in Pennsylvania; sign and agree to the conditions in the CDC COVID-19 Vaccination Program Provider Agreement; and also fully complete the CDC COVID-19 Vaccination Provider Profile form for each location where COVID-19 vaccine will be administered. Please note that federal clinicians working in federal facilities may have professional licensure from a different jurisdiction and that some national pharmacy chains and federal entities will be instructed to enroll directly with CDC. The forms are attached for your reference and more information about the enrollment process will be made available to you in the invitation letter, as well as on our website. We will also be providing an email address and phone number for you to submit the information and contact us with questions.
If you choose to enroll as a COVID-19 vaccine provider, we are committed to working closely with you throughout the enrollment process and beyond to assist with any identified training and technical assistance needs. We will also be sharing new information as it becomes available based on the frequent updates we are receiving from CDC.
COVID-19 Vaccination Program Provider Agreement Instructions
- Complete the CDC COVID-19 Vaccination Program Provider Agreement Section A form for each organization that will be applying to the CDC COVID-19 Vaccination Program.
- Complete the CDC COVID-19 Vaccination Program Provider Agreement Section B form for each facility (physical address) that will be administering the COVID-19 vaccine.
- Save a copy of each form for your records.
- Submit a copy of the CDC COVID-19 Vaccination Program Provider Agreement Section A for your organizations and the CDC COVID-19 Vaccination Program Provider Agreement Section B for each facility (physical address) that will be administering the COVID vaccine to the Pennsylvania Immunization Program using the following email address: firstname.lastname@example.org
For additional questions or information, please contact us at email@example.com or 717-787-5681.