How to Participate

Thank you for your interest in participating in the COVID-19 pandemic response!  To register as a vaccine provider, a CDC COVID-19 Vaccination Program Provider Agreement and a COVID-19 Vaccination Program Provider Profile Form must be filed with and approved by the Kansas Immunization Program (KIP). Follow these tips to complete enrollment:  

CDC COVID-19 Vaccination Program Provider Agreement 

Section A specifies the conditions of participation for vaccination provider organizations and their constituent facilities wanting to enroll in the U.S. COVID-19 vaccination program. Vaccine products will be available only to organizations that sign and agree to the conditions of this agreement, which is between CDC and the organization. The chief medical officer (or equivalent ) and chief executive officer or chief fiduciary signing this agreement must be the individuals who will be held accountable for compliance with the conditions outlined in the agreement. Failure to meet the conditions of the agreement may impact whether COVID-19 vaccine product orders are fulfilled. Find an example of this form in the Enrollment section.

CDC COVID-19 Vaccination Program Provider Profile Form 

Section B outlines key minimum data elements required by CDC to be collected from every vaccination provider location receiving COVID-19 vaccine, ancillary kits and/or administration kits. Each location that plans to offer COVID-19 vaccine must complete a provider profile that includes each prescribing provider at that location, with a maximum of 25 providers listed. The vaccine coordinator listed on this form is the individual who will be responsible for receiving vaccine shipments, monitoring storage unit temperatures, managing inventory, etc. This form must be fully completed, and the medical/pharmacy director or vaccine coordinator must provide a signature attesting to the ability of any listed COVID-19 vaccine storage units to maintain required temperature ranges. 

Validation, State Immunization Registry & Training

Once the forms are completed, the KIP will validate professional licensure information for each prescriber listed in Section B. The KIP will also ensure COVID-19 approved facilities are able to submit data into the state immunization registry, KSWebIZ, via direct data entry or HL7 exchange.  When providers receive final approval from the KIP, training will be scheduled on several topics related to the COVID-19 vaccine.  

Vaccine Provider Enrollment

 To help you get enrolled, take a look at the following:

Once you have had the opportunity to review these documents, begin the electronic enrollment process.  Questions or issues can be resolved via phone at 877-296-0464 or by email