Vaccine Hesitancy KS Training Attestation

1

Your Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Pharmacy Name* This field is required.DBA name, please.

4

NCPDP* This field is required.Please provide your NCPDP number for the pharmacy

5

Training Complete* This field is required.I confirm that at least one pharmacist and one technician in our store have viewed the Vaccine Gap Closure Training Session (live on Jan 31 or located on CPESN KS website)

I attest

6

Medication Synchronization* This field is required.I confirm that our pharmacy meets the minimum requirements for a medication synchronization (care sync, etc) program for this program. Minimum requirements: 1) Speak to a patient 2-4 days prior to medication pick-up 2) Document intervention in a clinical platform and/or on paper documents provided

I attest

7

Health Equity Expertise* This field is required.I confirm that our pharmacy meets the minimum requirements for health equity expertise Minimum staffing requirements (one of the following): 1) A Community Health Worker (CHW), or 2) A CHW in Training (enrolled in a CHW course), or 3) Completion of the CPESN HE SDOH Training

I attest

8

W9* This field is required.Please upload a copy of your pharmacy's W9

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Max. file size: 10.6MB

9

ACH Information* This field is required.Please confirm the payee and address where Kansas Pharmacists Association should send checks for services rendered as a part of this grant.

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Max. file size: 10.6MB