Maine Immunization Program - Information for Providers

Forms and Updates

This page is being developed to provide one location for providers to be able to download the recommended forms and informational materials. Please check back, as we will be making a concerted effort to get most of our available papers on-line.

Date Revised Title

Material Order Forms

04/2014 Educational Material Order Form (Microsoft Excel*)
Patient Record Information
03/2013 Patient Eligibility Screening Record Vaccines for Children Program (Adobe PDF*)
10/2011 Sharing of school health records (Microsoft Word*)
01/2008 Client Vaccine Administration Form Template (Microsoft Word*)
01/2008 Client Exemption Form Moved Or Gone Elsewhere (M.O.G.E.) (Microsoft Word*)
12/2010 Immpact reenrollment form (Microsoft Word*)
12/2010 Non-Participation Form (Microsoft Word*)

Provider Enrollment Agreement

12/2013 2014 Maine Immunization Program Provider Vaccine Agreement (Adobe PDF*)
12/2013 2014 Provider Agreement Cover Letter (Microsoft Word*)
05/2014 ImmPact User Agreement (Adobe PDF*)
06/2011 ImmPact Rules (Microsoft Word*)
01/2011 Immpact user confidentiality and security policy (Microsoft Word*)

Storage and Handling

02/2013 Vaccine Manufacturer contact information (Adobe PDF*)
11/27/13 Varicella/MMR-V Eligibility Request Form (Microsoft Word*)
06/2014 Updated Vaccine Storage and Handling Toolkit 2014
01/2014 Recalibration form for thermometer (Microsoft Word*)
03/2014 Refrigerator Temperature Tracking Form - Page 1 (Adobe PDF*)
03/2014 Refrigerator Temperature Tracking Form - Page 2 (Adobe PDF*)
03/2014 Freezer Temperature Tracking Form - Page 1 (Adobe PDF*)
03/2014 Freezer Temperature Tracking Form - Page 2 (Adobe PDF*)
01/2008 Storage, Handling, and Emergency Protocol Instructions (Microsoft Word*)

Vaccine Management

04/2013 Submit Expired and Non-Viable State Supplied Vaccine (Microsoft Word*)
04/2010 Use of Open Multidose Vaccine Vials Policy (Microsoft Word*)
02/2009 Order Forms are now specific to the provider site, please call for your specific order form replacement.

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  • Please feel free to provide feedback or session request through the Support Services call line @ 1-800-867-4775, 8:00am-5:00pm,  Monday thru Friday
  • Fax Completed Forms to: 1-800-437-5743 and 1-207- 287-8127
  • For more information: Call 287-3746 or 1-800-867-4775 8:00am-5:00pm,  Monday thru Friday