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TVFC and ASN Program NEW Enrollments

IMPORTANT NOTE: New enrollments for the TVFC and ASN Programs will be suspended from October 1, 2018 through December 31, 2018 due to the annual re-enrollment period for both programs. New enrollments received during this time will be processed beginning January 1, 2019.

Welcome to the DSHS Texas Vaccines for Children/Adult Safety Net Program enrollment.

DSHS requires all enrolling sites to complete this Program Agreement. Required fields are marked with an *. Prior to starting your enrollment, gather the following information:
 

  • ImmTrac2 org code: If your site does not have an org code you must register with ImmTrac2 to receive one. Information regarding ImmTrac2 organization code may be found in the 2019 TVFC/ASN Provider Manual Chapter 7: Documentation Requirements and on the ImmTrac2 webpage www.dshs.texas.gov/immunize/immtrac.
  • Facility name, address, phone, and fax
  • Signing clinician's name, title, email, medical license number and NPI.
  • Primary and backup vaccine coordinator's name, email.
  • Training requirements: Before completing this agreement, DSHS requires that your primary and back-up vaccine coordinator complete the following:
  • List of all practitioners at your site with prescribing authority to include name, title, medical license number and NPI.
  • For TVFC: Locate and calculate the number of children seen in your facility in the previous 12 months in the following categories, separated by age groups (under one year of age, one to three, four to six, and seven to 18 years of age). This information can be collected from your filed Medicaid claims, your vaccine doses administered, your billing system or your encounter data. It is necessary for the data to be separated into TVFC-eligibility categories:
    • Enrolled in Medicaid or Medicaid-Eligible
    • UNinsured
    • American Indian/Alaskan Native
    • UNDERinsured
    • CHIP
    • Insured
  • For ASN: Locate and calculate the number of UNinsured and insured adults that were seen in your facility in the previous 12 months.
  • Clinics that are new to the TVFC/ASN Program should include a projection of patients that you will serve in the upcoming year (including insured patients). 
  • Number of refrigerators and freezers that contain TVFC or ASN vaccine.
  • Number of data loggers, including a backup, that monitor the temperatures of the refrigerators and freezers.
  • Facilities that are a Federally Qualified Health Center (FQHC) and a Rural Health Center (RHC)  must also submit a copy of the Centers for Medicare & Medicaid Services (CMS) letter designating the sites as such.

Tips for completing the DSHS Program enrollment agreement:

  • Ensure the latest version of your web browser is installed. Certain portions of the form may not function unless your web browser is up to date.
  • Do not use the web page back arrow button at the top left of your screen when filling out this document. It is important to go to the bottom of the page to use the RED "BACK" button.
  • If you need to gather data and continue your survey at a later time, go all the way to the bottom of the page to find the grey bar with "Save and Continue Later". If you leave the survey without selecting "Save and Continue Later", all of your data will be lost and you'll have to start again. By selecting "Save and Continue Later", you will be asked to enter an email address. A unique link will be sent to that email address which will give you an opportunity to continue the survey where you left off.     
 

Thank you for your interest in the TVFC and/or ASN Program. We look forward to having you as a member of our team!

If you have any questions, please contact us via email to TVFCenrollment@dshs.state.tx.us or call 512-776-6244.