COVID-19 Vaccination Program Provider Agreement
The Pennsylvania Department of Health welcomes existing partners who may already be a part of Pennsylvania's Immunizations Program (e.g., Vaccines for Children, TotTrax) as well as new partners to enroll as providers in Pennsylvania's COVID-19 Vaccination Program.
Please note that our plan for vaccine distribution includes a phased approach, therefore we may need to prioritize enrollment to align with the phases. For example, in Phase 1A we may need to prioritize enrollments for providers best positioned to reach those in Phase 1A populations.
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.
If you choose to enroll as a COVID-19 vaccine provider, please complete the COVID-19 Vaccination Program Provider Agreement (see below). Upon submission, you will receive a notice of receipt. If additional information is necessary, someone will reach out to you directly, otherwise consider your enrollment agreement to be in process.
There are a number of steps to the enrollment process, including the requirement for providers to be established and trained in the use of the Pennsylvania Statewide Immunization Information System (PA-SIIS) specifically for the COVID-19 Vaccination Program. When it is time for those steps to be completed, you will receive a second notice with more information. Please do not submit duplicate agreements as this will delay the processing of your enrollment. While your enrollment agreement is being processed, we encourage you to review the resources which can be found at the links provided to the right.
*** All providers choosing to enroll as a COVID-19 vaccine provider must complete the electronic agreement form. Below are PDF versions of the agreement form to be used as a reference when completing the electronic version. You do not need to complete the PDF versions of the agreement form to enroll as a COVID-19 vaccine provider.
Questions from providers* may be directed to:
firstname.lastname@example.org or 717-787-5681
*Please note: this contact information is intended for questions from COVID-19 Vaccination Program providers, or those wishing to enroll. If you have a question about the COVID-19 vaccines, please visit our website at
https://www.health.pa.gov/topics/disease/coronavirus/Pages/Vaccine.aspx or call the PA Health Hotline at 1-877-724-3258
Frequently Asked Questions