2017 Replacement Method of Vaccine Management
Agreement
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Complete, sign, and submit a 2017 Replacement Method of Vaccine Management Agreement by November 30 each year. We
prefer you complete an online version of this form which is available on the Replacement Method Sites
(www.health.state.mn.us/divs/idepc/immunize/mnvfc/replacement/index.html). The paper version of this form can be
returned by email or mail. The use of fax is discouraged.
Systems may sign one 2017 Replacement Method of Vaccine Management Agreement on behalf of all sites using the
replacement method within the system. A list of the MnVFC PINs for all of the sites included in the agreement must be written
on the agreement or be attached.
If you fail to submit the 2017 Replacement Method of Vaccine Management Agreement and/or meet the requirements, you
will be required to switch to the separate stock method of vaccine management.
Organization Information
Organization name:
MnVFC PIN(s) – additional space on
back:
The Minnesota Vaccines for Children (MnVFC) program, administered by the Minnesota Department of Health (MDH), has authorized
the organization represented on this form to use the replacement method of accounting for vaccine provided by the MnVFC program in
lieu of maintaining physically separate stocks of MnVFC-provided and privately purchased vaccine. The organization agrees that all
practitioners associated with the organization will follow these replacement method procedures:
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Use privately-purchased vaccine to vaccinate MnVFC-eligible children and order doses from the MnVFC program to replace
those doses. The organization must order MnVFC vaccine based on the number and type of doses administered to eligible
patients. The doses ordered must be for the same type of vaccine that was administered (for example, Hepatitis A vaccine can
only be replaced with Hepatitis A vaccine). The MnVFC program coordinator may grant occasional one-time deviations from
this requirement to address exceptional circumstances. Replacement doses must only be ordered for doses administered at
sites that are enrolled in the MnVFC program and approved to use the replacement method.
When a patient age 18 years or younger is immunized, determine the patient’s MnVFC eligibility with respect to each individual
dose of vaccine administered. Document this determination by submitting dose-level eligibility to the Minnesota Immunization
Information Connection (MIIC).
Adhere to requirements set forth in the MnVFC Replacement Method Sites: Policies and Procedures Manual.
Cancellation: This organization or the Minnesota Department of Health may terminate this agreement at any time. The
organization must terminate this agreement in writing. If the agreement is terminated, the organization will cease to use the
replacement method of vaccine management and will follow the requirements for the separate stock method of vaccine
management.
Effective date: The effective date of this agreement is January 1, 2017.
Expiration date: This agreement will remain in effect until January 1, 2018.
By signing this form, I certify, on behalf of myself and all immunization providers in this organization, that I have read and agree to
the requirements listed above and understand that noncompliance with these requirements may cause the Minnesota Department
of Health to cancel this agreement.
Individual authorized to sign on behalf of the organization (print):
Signature:
2017 Replacement Method Agreement
Date:
(July 2016) Page 1 of 2
Additional PINs (You can also attach a list of additional PINs.)
PLEASE RETURN THIS FORM BY EMAIL OR MAIL TO:
Email: [email protected]
Minnesota Department of Health
MnVFC Program
P.O. Box 64975
St. Paul, MN 55164-0975
2017 Replacement Method Agreement
(July 2016) Page 2 of 2