Your interest in participating in the MS Pandemic Agreement vaccination effort is greatly appreciated as a vital service that will protect individuals and the public against COVID-19 . To ensure that you are prepared to meet the requirements for participating in this effort, you will need to complete a multi-step enrollment process. All signature forms must be signed by a provider who is licensed in the state of Washington to prescribe vaccines and is responsible for making decisions about the clinic and its operations.

Completing the enrollment forms could take 15 to 20 minutes. You will need the following information available to complete the forms.

• Facility details - physical address, vaccine delivery address, and mailing address (if different)
• Contact details - names, email addresses, telephone and fax numbers.
• Shipping details - days and times available to receive vaccine shipments.
• Physician/Vaccinator details - name, designation, Washington State Medical License Number, and National Provider ID for each physician/vaccinator in your practice.
• Certified thermometer details.
• Estimated number of patients to be vaccinated.

Step 1 - Provider Agreement - for receipt of publicly supplied vaccine
            You must complete all required fields in each section of the form to proceed to the next step.
            You will need to print, sign, and fax the signature page of the agreement to the MS State Department of Health .
            You should print a complete copy of the agreement for your records.

Please click the Continue button to begin or click the Print button to print these instructions.

If you have questions regarding the enrollment process or any of the following forms, please contact the MS State Department of Health at (601)576-7751 .