Wyoming COVID-19 Vaccine Information for Providers

The Wyoming Immunization Unit is excited to begin enrolling COVID-19 Vaccine Program Providers. Enrollment is required to receive COVID-19 vaccine from the Unit. The Immunization Unit thanks you in advance for working with us to ensure the success of the COVID-19 vaccination efforts in Wyoming. 

The link to the PDF version of the COVID-19 Vaccination Program Provider Agreement is below. It is very important that you read through and then follow the instructions provided here to ensure successful completion.

There are two parts to the Provider Enrollment Agreement:

1. Section A
   1. COVID-19 Vaccination Program Provider Requirements and Legal Agreement: This section must be completed with information about the Organization.
2. Section B
   1. CDC COVID-19 Vaccination Program Provider Profile Information: This section must be completed for each location (one or more) where individuals will be vaccinated, whether the location receives COVID-19 vaccine directly shipped or vaccine transferred from another location. 
   2. For example:
      1. The Organization has five associated facilities, including the main facility. Only three of these facilities, including the main one, will administer COVID-19 vaccine when it is available. Two of the three facilities intend to receive shipments of the vaccine directly; however, the third location will receive doses from one of the other associated facilities.
         1. Three total PDF Agreements will need to be completed and sent back to the Immunization Unit. Section A will be the same for all three documents. Section B will be specific to each individual facility. 
3. We recommend that if there is more than one facility that will be enrolled as a COVID-19 Vaccine Provider location you complete the information in Section A and then save a copy for each of the associated locations. This will alleviate the need to re-enter the information into Section A each time.
4. All information needs to be completed in the electronic format of the Agreement, including signatures. Please do not print the form at any time during this process.
5. Once the information is entered into the PDF and all electronic signatures are obtained, you will need to save the file and email it back to the Immunization Unit. Tips for this process are as follows:

1. 1. Open the PDF attachment (download a free version of Adobe Reader, if necessary)
   2. Save a copy of the document in a known location such as your Desktop, Documents, or other folder,
      1. File > Save As > [select the desired file location] > Save
   3. Complete the form fields,
   4. Save the PDF,
   5. Close the PDF,
   6. Attach the PDF in an email to wdh.covidenrollment@wyo.gov. 

After the Immunization Unit reviews the information and processes the form, the contacts listed will receive an email with information and next steps. Please expect at least two weeks before receiving additional information as we are working to finalize the onboarding process.   

The Immunization Unit can answer questions you may have by emailing wdh.covidenrollment@wyo.gov with questions.

You are also encouraged to utilize the Provider Enrollment Agreement Form FAQ document.

Wyoming COVID-19 Vaccine Program Provider Enrollment Agreement