NCIP Provider Update Request Form

Enrolled NCIP providers can use this form to submit requests to update key information including: facility name change, change in lead provider, change in vaccine coordinator(s), and change of address.

 
 
 

Select "Not Listed" if your location does not appear in the dropdown

 

An updated provider agreement must be submitted with facility name or lead provider change. You can submit an agreement electronically at one of the links below. Please be sure to use the link for your facility type.


Local Health Department Agreement

Private Provider Agreement (birthing hospitals, private providers, FQHCs, etc.)

Adult-only Provider Agreement