COVID-19 Vaccine Provider Agreement Form

Our COVID-19 Provider Agreement form is here!

All sites intending to distribute COVID-19 vaccine must enroll as a provider. All medical facilities who regularly provide vaccine are eligible to enroll into our COVID-19 vaccine program.

Please refer to our Provider Agreement Guide to enroll as a provider for the COVID-19 vaccine.

Please review the Provider Agreement Guide in its entirety before filling out the agreement form and survey.

The agreement and survey form can be accessed here.

If you have any questions, contact our team at vaccines@phila.gov.