Provider Forms and Information
COVID-19 Vaccine Distribution and Reporting (1/11/2021)
To be able to order COVID-19 vaccine online, receive distributions of vaccine, and fulfill mandated reporting of COVID-19 immunizations to the CDC, your organization, clinic sites, and staff members must be enrolled in the RIDE/Healthy Futures Immunization Registry:
- Step 1: Register your organization and clinic sites - Complete and return a Registry Provider Agreement Form. You will be issued an "IIS ID", which is required for enrollment in COVIDReadi/CalVax to be eligible for COVID-19 vaccine distribution.
- Step 2: Register your staff members - Complete and return a Registry Request For Access Form for each member of your staff who will be entering immunizations and/or managing vaccine inventory. Note that at least one person on your team must be designated as a Clinic Administrator, to allow them to manage vaccine inventory and request COVID-19 vaccine.
- Step 3 (optional): Set up Electronic Data Exchange - If your organization would like to send data electronically from your EHR system, please click here for more information. This is not required for COVID-19 vaccine distribution.
Once your organization, clinic sites, and staff members are enrolled, your COVID-19 immunizations will be automatically reported to CDC.
If you have any questions, please contact the Registry Help Desk at:
- Phone: (209) 468-2292
- Email: support@myhealthyfutures.org
To further assist our provider community, this section of the website provides forms, documentation, and links to information about important immunization topics.
Documents
Provider Forms
- Registry Provider Agreement (Updated: 01/21/21) NOTE: Currently enrolled providers should complete and return this form to the Help Desk as soon as possible. Please refer to the document for instructions.
- Registry Request For Access user form (Updated: 09/20/20)
Patient Disclosure
NOTE: The Patient Disclosure forms below REPLACE all previous copies. Currently enrolled providers should discard their old forms and begin using the forms below.
- Patient Disclosure (English) (Updated: 10/24/13)
- Patient Disclosure (Spanish) (Updated: 10/24/13)
- OH Consent Form (English) (Updated: 09/13/23)
- OH Consent Form (Spanish) (Updated: 09/13/23)
Patient Refusal
- Sharing/Reminder Refusal Form (English) (Updated: 05/25/18)
- Sharing/Reminder Refusal Form (Spanish) (Updated: 05/25/18)