*The online form cannot be saved. Please collect all your information and enter the information into this online form.
*Be prepared to UPLOAD the following items before starting this form:
1. Training certificates for the designated primary vaccine coordinator, secondary vaccine coordinator, and the Provider of Record (MD, DO, PA, NP) contacts.
2. The signed CDC Provider Agreement and Colorado Supplemental Agreement.
3. The refrigerator and freezer thermometer calibration certificates.
*Be prepared to ENTER the following item in this application:
1. Enter all MDs, DOs, NPs, and PAs' medical license numbers and Medicaid or NPI numbers.
Download the training instructions and agreements here:
Colorado VFC Annual Training Course Instructions
CDC Provider Agreement
Colorado Supplemental Agreement
*Hit the SUBMIT button at the end of this form. After SUBMITTING the enrollment application, an email confirmation will be sent. Keep a copy of the enrollment application.
Please contact the VFC Program at cdphe_vfc@state.co.us or 303-692-2650 if you have questions or need additional information.