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New Jersey Immunization Information System

Enrollment Request for New Sites and Provider Groups

The following information is required to set you up as an NJIIS State Site and Provider; please fill out this form completely.
Fax the completed form to your local MCHC office.

Provider Name:
Provider Group Name:

VFC ID:

Tax ID (EIN):
-
Site Administrator:

 
Site telephone Number:
-- Ext.
Email:

Site Address:

City:

State:
  Zip:
County:

Vaccine Inventory (Check if you will be using the following):
 
Public Stock Private Stock Both Will not use

Type of Facility:
Public Health Department Private Hospital
Public Hospital Other Private
Other Public Federally Qualified Health Care (FQHC)
Private Practice (Individual or Group) Other Immunization Project
Public School College
Private School  

List the names of all the users from your site who will need access to this provider:
1)
2)
3)
4)
5)
6)


   

 

This system is restricted to authorized users. Random audits are routinely performed.
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