GlaxoSmithKline: VAP Prescribers

Prescribers

Prescribers register online, one time, to participate in the program. The registration process will require prescribers to attest to being a licensed practitioner eligible under state law to prescribe, receive and administer vaccine and that the information provided on the application and Dose Authorization Request Form is accurate to the best of the prescriber’s knowledge. Further that they understand that the program is available to patients at no cost and that prescribers will receive no reimbursement from the program.

At time of registration prescribers will also be required to provide:
- First and last names
- Name of clinic
- Primary address
- Shipping address for vaccine replenishment (be sure to provide the shipping address for any location where you may want replenishment sent through the program)
- State License number (for each state where you may administer vaccine through the program)
- Email address
- Phone and fax numbers
Prescriber responsibilities:
- Help the patient complete the application and sign.
- Fax the patient's application with proof of income and insurance information and receive enrollment notification.
- Deliver the vaccination according to program guidelines once the patient has been determined eligible.
- Submit Dose Authorization Request Forms for subsequent doses when needed by patients already enrolled in the program.
Once the prescriber submits the registration form and the requested information on-line, a notification will be returned immediately regarding acceptance into the program. The notification will include a prescriber registration number to be used for the patient's application and/or a Dose Authorization Request Form for subsequent doses.

For questions, call the GSK Vaccine Access Program at 1-877-VACC-911, Monday – Friday, 9:00 am – 7:00 pm, ET.