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ND DoH NDIIS Provider Site Agreement free printable template

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North Dakota Department of Health Immunization Program 2635 East Main Ave., P.O. Box 5520 Bismarck, ND 585065520 Email: NDIIS@nd.govProvider Site Agreement North Dakota Immunization Information System
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How to fill out ND DoH NDIIS Provider Site Agreement

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How to fill out ND DoH NDIIS Provider Site Agreement

01
Obtain the ND DoH NDIIS Provider Site Agreement form from the North Dakota Department of Health website.
02
Review the instructions provided with the agreement form to understand the requirements.
03
Fill in the provider's details including name, address, and contact information in the appropriate sections.
04
Provide the credentials and license information required for the provider to operate.
05
Sign and date the agreement where indicated.
06
Submit the completed form to the designated address provided in the instructions.

Who needs ND DoH NDIIS Provider Site Agreement?

01
Healthcare providers who wish to participate in the North Dakota Immunization Information System (NDIIS).
02
Hospitals, clinics, and any medical facilities that administer vaccines.
03
Providers looking to access and report immunization records within the NDIIS.
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The ND DoH NDIIS Provider Site Agreement is a document that formalizes the relationship between healthcare providers and the North Dakota Department of Health regarding the reporting and management of immunization data within the North Dakota Immunization Information System (NDIIS).
Healthcare providers, including clinics, hospitals, and other entities that administer vaccines and wish to participate in the NDIIS, are required to file the ND DoH NDIIS Provider Site Agreement.
To fill out the ND DoH NDIIS Provider Site Agreement, providers must provide accurate information regarding their facility, including contact details, type of services provided, and ensure all required signatures are obtained before submission.
The purpose of the ND DoH NDIIS Provider Site Agreement is to ensure compliance with data reporting standards, facilitate the secure exchange of immunization information, and enhance the overall effectiveness of the immunization program in North Dakota.
The information that must be reported on the ND DoH NDIIS Provider Site Agreement includes provider identification details, types of vaccines administered, data privacy and security measures, and agreements on data sharing protocols.
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