Healthy Communities

CDC COVID-19 Vaccination Program Provider Agreement

Please click here or use the link below to submit a COVID-19 provider agreement form to the Arkansas Department of Health. You can also print a CDC provider agreement form here to help you gather the necessary information, but you must enter the data into the electronic form in order to submit it to ADH.

The video below has additional information about the process.

Public Health Accrediation Board
Arkansas Department of Health
© 2017 Arkansas Department of Health. All Rights Reserved. www.healthy.arkansas.gov
4815 W. Markham, Little Rock, AR 72205-3867
1-800-462-0599