Online Covid-19 Provider Vaccination Registration Form

MDHHS Releases a New Online COVID-19 Provider Vaccination Registration Enrollment Form

On 11/30/2020, MDHHS, Division of Immunizations released a new online COVID-19 Provider Vaccination Registration form*. Health Care Organizations, Pharmacies and Providers who plan to participate in the administration of the COVID-19 vaccine may now enroll.

Please note: Hospitals and Local Health Departments – If you have already completed an application via the previous fillable PDF enrollment form, you do not need to repeat an application.

Links to information and the online application can be found at https://www.michigan.gov/coronavirus/0,9753,7-406-98178_98156—,00.html

To assist with preparation to complete the application, this link includes a sample COVID-19 Provider Registration form (Section A and Section B). Additionally, there is a Registration Frequently Asked Questions (FAQ) document that has information on how to enroll in the Michigan Care Improvement Registry (MCIR) which is a pre-requisite to applying to be a COVID-19 provider.

All Health Care Providers who intend to provide COVID-19 vaccinations must complete an application to be eligible to provide this vaccine. Approval does not automatically mean that you will receive vaccine immediately. Please reference the MDHHS Vaccination Plan for information on priority groups and distribution plans.

Pharmacies who are already participating at the Federal level (federal pharmacy contract to vaccinate LTC/SNFs) SHOULD NOT apply at the Michigan level. HOWEVER, these pharmacies need to be registered in MCIR (see FAQ sheet for information on how to get registered in MCIR).

Health Care Providers who are already enrolled to provide Flu vaccinations and intend to provide COVID-19 vaccinations, must also complete COVID-19 registration to be eligible for the CDC COVID-19 Vaccination Program.

Questions on registration can be sent to MDHHS: COVIDVaccineProviders@michigan.gov

*If you are unable to access the new online COVID-19 Provider Vaccination Registration form via the website, an additional direct link is available here: https://redcap.mphi.org/surveys/?s=EKNWTKMFJC

Thank you,
Michigan Health Alert Network

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