SITE INFORMATION

Name of Site being Enrolled*: (Please select from the list of drop-down options.)
Correctional Facility Family Practice Federally Qualified Health Center Hospital Long Term Care/Assisted Living Military Pediatric Practice Pharmacy Rural Health Center Tribal Health Clinic Urgent Care Center

Street Address*: (Street number and name for the Site being Enrolled.)

Street Address: (Include additional needed information, e.g.: Suite 300, Room 400 West.)

City*:   State*:  

Zip Code*: (Provide the five digit zip code of the Site being Enrolled.)

POINT OF CONTACT (POC) INFORMATION

Name of Facility:* 

Name of the person who will be signing for the Antivirals:*

Name of the person who is the H1N1 Point of Contact (POC) for the site:*

Phone number for the Site’s POC:* (Provide the full ten digit number with area code.)

Fax number for the Site’s POC:* (Provide the full ten digit number with area code.)

Email Address for the Site's POC:

PRESCRIBER INFORMATION

Name of Prescriber for the Site:* (Please provide the name of one of the prescribers (e.g.: MD or DO) under whose authority antivirals are dispensed at the Site. (Even if the Site has multiple prescribers, please only list ONE at this time).

Prescriber’s Medical License Number:*

ANTIVIRAL SHIPPING INFORMATION

Amount, courses, and type of Antivirals requested (check all that apply)

Number of courses this facility would dispense in a week:

Print this Enrollment Form! Nevada State Health Division recommends you print a copy of this completed form BEFORE you hit “Submit.” You will NOT be able to print a copy after submission. Please retain a copy of this form for your records.

To finish the Enrollment process, click “Submit” at the bottom of this page after you have completed and printed this form. Follow up from the Nevada State Health Division will occur as applications are screened.