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.