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2021 TVFC and ASN Programs Re-Enrollment Form


Welcome to the 2021 Texas Vaccines for Children (TVFC) and Adult Safety Net (ASN) Programs Re-Enrollment

DSHS requires all re-enrolling sites to complete and submit all sections of this form. If you fail to complete this re-enrollment form in its entirety, your ordering privileges may be suspended.

Prior to starting your re-enrollment, gather the following information:

  • TVFC/ASN PIN: This information is required to begin the survey to complete your re-enrollment form. If you do not know your TVFC/ASN PIN, contact your Responsible Entity (RE).
  • Primary and backup vaccine coordinator's first and last name.
  • Training Requirements: Before completing this re-enrollment, DSHS requires that your primary and backup vaccine coordinators complete the following:
    • 2021 TVFC/ASN Provider Policy Training, available at
    • Once the module is completed, it is important to save copies of the Certificates of Completion as PDF files. You will be prompted to upload these certificates as you progress through the re-enrollment.
  • For TVFC: Number of children that were vaccinated in your facility in the previous 12 months in the following categories, separated by age groups (under 1 year of age, 1 to 3 years of age, 4 to 6 years of age and 7 to 18 years of age). This information can be collected from your doses administered data, Medicaid claims, encounter data or your billing system.
    • Enrolled in Medicaid or Medicaid-eligible
    • UNinsured
    • American Indian/Alaskan Native
    • UNDERinsured
    • Enrolled in CHIP
    • Insured - This information serves as verification for accountability of the TVFC/ASN Program to ensure federal- or state-supplied vaccines are not administered to ineligible clients.
  • For ASN: Number of UNinsured and Insured adults that were vaccinated in your facility in the previous 12 months.
  • Number of refrigerators and freezers that store TVFC or ASN vaccine.
  • Number of data loggers, including a backup, that monitor the temperatures of the refrigerators and freezers.
  • Calibration Certificates or Reports of Calibration: Before completing this re-enrollment, DSHS requires all re-enrolling providers to upload current and valid certificates for all data loggers that are used to monitor the temperatures of the storage units, including the backup.
    • You will be prompted to upload the certificates as you progress through the re-enrollment.
  • 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 2021 TVFC and ASN Programs Re-Enrollment:

  • Ensure that 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.
  • Users will receive an alert message for select questions when the field is incomplete (no data entered). To clear the alert message, users must enter data in the notated field. Until the selected field has been completed (data entered), users cannot continue on to the next page of the survey. 
  • 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" link. 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 and 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 continued support of the TVFC and ASN Programs. We hope your re-enrollment is a success. If you have any questions, please contact your Responsible Entity below.

Thank you for continuing to participate in the TVFC/ASN Program to keep Texans healthy by preventing and controlling vaccine-preventable diseases.