Health and Seniors Care

COVID-19 Vaccine Program Registration Form For Medical Clinics

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COVID-19 Vaccine Program Registration Form For Medical Clinics

Medical Clinics that would like to participate in Manitoba’s COVID-19 Immunization Program must register with Manitoba Health and Seniors Care and identify that they can meet all the requirements identified on COVID-19 Vaccine Program Requirements document.

Please submit only ONE registration form per medical clinic

If you have questions about how to fill out this online registration form, please email covid@gov.mb.ca

Facility Information

Client ID#

Note: Client ID # (also referred to as a Holding Point Code – it is the number your location uses to order publicly funded vaccines through the Provincial Distribution Warehouse)

Health Region

Facility Name

Delivery Address

Street Number and Name/PO Box/RR

City or Town

Province

Postal Code

Contact Information

Please provide information of a Office Vaccine Coordinator or Contact Person.

Please note: this individual will be the main point of contact for your entire facility with regards to ensuring that program requirements are met as well as notification of product allocations, status of applications, etc

Contact Name:

Email Address:

Phone Number:

Fax Number:

List of Immunization Provider

Please list ALL immunization providers within your clinic/facility and identify if they also offer immunizations at another location. If so, please provide the name of the alternate clinic or facility as well as the address.

Immunization Provider

Full Name of Immunization Provider

Alternate Location Address (if applicable)

Clinic/Facility Name

Street Number and Name/PO Box/RR

City or Town

Province

Postal Code

Current method of recording vaccine administrations:

The Claims Processing Solution (CPS) is the provincial system used to process claims for payment. Weblink or EPiCs is the interface used to submit claims to CPS.

Authorization

Submitting this form indicates that you, on behalf of the medical clinic, have reviewed and will follow the COVID-19 Vaccine Program Requirements to participate in Manitoba’s COVID-19 Immunization Program

Full Name

Date

I have reviewed and will follow the COVID-19 Vaccine Program Requirements to participate in Manitoba’s COVID-19 Immunization Program I agree I disagree