Medicaid Data Sheet

Medicaid Data Sheet
It is not a VFC enrollment requirement to submit all providers and their NPI#. However, if you want Medicaid to pay the administration fee for VFC vaccine, AL VFC Program must submit each provider's Medicaid number, effective date, and their NPI to Medicaid.

* Contact Name

* Contact Phone and Area Code

* VFC Clinic Name

* VFC PIN Number
If this is a new VFC provider site, enter "New Enrollment."

* Name of Provider

* Title (MD, CRNP, NEP, PA, etc.)

* Provider's NPI Number
Ten-digit number

* Provider's Medicaid Number

* Effective Medicaid Date

To add an additional provider go to page 2.