Entity Enrollment Form
PhilaVax
November 2020 | [email protected]
Philadelphia Department of Public Health - Divison of Disease Control - Immunization Program
1101 Market St. Floor 12, Philadelphia, PA, 19107 | vax.phila.gov | [email protected]
1
I. Background
Pursuant to its public health authority under section 6-210 of the Philadelphia Health Code, the Philadelphia Board
of Health has issued Regulations that mandate reporting of immunization data for children 0-18 years of age and adults
over 18 years of age to a citywide immunization registry. The Philadelphia Department of Public Health (PDPH), Immunization
Program maintains the PhilaVax Immunization Information System, heretofore referred to as PhilaVax, to record all
immunization data.
PhilaVax is a secure web-based application that oers medical providers consolidated immunization records for their patients
as well as recommendations based on the most recent immunization schedule. PhilaVax can be accessed via the internet
(https://vax.phila.gov) and directly through Electronic Health Record Systems via Web Services. All healthcare providers
who administer immunizations in Philadelphia are required to report all vaccine doses, whether supplied by Vaccines for
Children (VFC), Vaccines for Adults at Risk (VFAAR) programs or privately purchased.
PhilaVax is available to the employees of Philadelphia health care entities, schools, social service agencies, as well as, PDPH
employees and their select representatives. Responsible entities of any health care organization, authorized agency, or
school who will be given access to PhilaVax data, via manual or electronic means, must complete and sign the PhilaVax
Responsible Entity Security and Condentiality Agreement.
II. Condentiality
Protecting the privacy of patients and the security of information contained in PhilaVax is an important priority for the
Philadelphia Department of Public Health.
PhilaVax data are confidential. Breach of confidentiality requirements (See Section V. Access to and Disclosure of
PhilaVax Information) will subject the user, health care entity, authorized agency, or school to termination of electronic
access to the PhilaVax and may result in civil or criminal penalties for improper disclosure of health information. Access to
the PhilaVax is password-protected with Secure Sockets Layer (SSL) encryption, and the database is protected by rewall
from unauthorized access.
PhilaVax is HIPAA compliant. HIPAA regulations do not prohibit covered entities or their business associates from reporting
notiable diseases/conditions or events, such as immunizations, to public health authorities Submitting data on reportable
diseases/conditions or events does not require covered entities to seek patient authorization for release of information,
nor to document that information will be disclosed to public health authorities.
If requested, the PhilaVax Disclosure Form is available to provide an explanation to patients, parents and/or guardians that
information about their immunizations or their child’s immunizations will be recorded in PhilaVax. This disclosure form
can be found on the PhilaVax website or by contacting the PDPH Immunization Program. Patients, parents, guardians or
legal custodians may opt-out of participation in PhilaVax.
Entity Enrollment Form
PhilaVax
November 2020 | [email protected]
Philadelphia Department of Public Health - Divison of Disease Control - Immunization Program
1101 Market St. Floor 12, Philadelphia, PA, 19107 | vax.phila.gov | [email protected]
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III. Notication
Providers are not required to obtain a release or authorization from patients, parents, or guardians to report immunizations
to PhilaVax. Pursuant to its public health authority under section 6-210 of the Philadelphia Health Code, the Philadelphia
Board of Health has issued Regulations stating that PDPH “…has the authority to obtain and store medical information,
including photocopies of medical records and medical summaries, regarding immunizations governed by this Regulation
without a signed authorization from the patient or patient’s representative.”
In addition, HIPAA Section 164.512 (b)(1)(i) allows disclosure for public health activities to “a public health authority that
is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or
disability…the conduct of public health surveillance, public health investigations, and public health interventions…”
IV. Patient Participation
Every person receiving immunizations in Philadelphia is enrolled into PhilaVax using information derived from the birth
record or health care provider.
A patient, parent, guardian or legal custodian can refuse to participate in PhilaVax and may have their record or their child’s
record locked by completing thePhilaVax Participation Request Form and submitting the completed form to PhilaVax
personnel. PhilaVax personnel will then update the patient’s record to indicate that data is not to be shared. If a PhilaVax
user subsequently tries to access that patient record, the user will be unable to view the patient’s immunization history
and personal information. Only PhilaVax personnel have the ability to view or unlock a locked patient record.
V. Access to and Disclosure of PhilaVax Information
The patient-level information contained in PhilaVax shall only be used for the following purposes:
• Assist providers and social service agencies in keeping a patient’s immunization status up-to-date including historical
validations and recommendations based on a pre-determined schedule.
• Prevent the administration of duplicate immunizations.
• Provide documentation of a patient’s immunizations (as reported to PhilaVax) to the patient, child’s parent, guardian
or legal custodian.
• Permit schools to determine the immunization status of students enrolled at that specic school.
• Provide or facilitate third party payments for immunizations (e.g. MCO).
PhilaVax data that identies individual patients will not be disclosed to unauthorized individuals, including law enforce-
ment, without the approval of the Director of the Division of Disease Control. Any request for PhilaVax data (including
subpoenas, court orders, and other legal demands) must be brought to the attention of the PhilaVax Coordinator, who
will consult PDPH legal counsel before any data can be released.
IMPORTANT NOTE: Any unauthorized use of PhilaVax data is prohibited, including the following:
• Accessing and/or distributing PhilaVax records for any activity other than those outlined above, including (but not
limited to) research, presentations, publications, sharing with unauthorized individuals.
Entity Enrollment Form
PhilaVax
November 2020 | [email protected]
Philadelphia Department of Public Health - Divison of Disease Control - Immunization Program
1101 Market St. Floor 12, Philadelphia, PA, 19107 | vax.phila.gov | [email protected]
3
VI. Responsible Entity Participation
Responsible entities are defined as a professional corporation, public agency or other entity or organization which is
authorized to provide healthcare services or contracted to assist in electronic data exchange. Any responsible entity
that has access to PhilaVax patient records via electronic means must read, complete and sign the PhilaVax Responsible
Entity Security and Confidentiality Agreement prior to gaining access to PhilaVax data. The following outlines the
functionality available to responsible entities via web services:
• View Demographics & Immunizations – the responsible entity has permission to view information about the
patient, including the patient’s name, date of birth, parent/guardian name, address, telephone number, the entire
immunization history and status (i.e., whether or not the child is up-to-date with recommended immunizations).
• Add/Edit Information - the responsible entity can add new demographic and immunization data to a patient’s
record; edit demographic and immunization data previously recorded in a patient’s record; and add a new patient
to PhilaVax.
The responsible entity is responsible for ensuring that all persons or entities (including providers, sta, contractors and
agents), who access information through PhilaVax are authorized to receive access to such information and will comply
with all the applicable laws, regulations and PhilaVax policies, including the condentiality and security agreement. Only
permanent and temporary employees, volunteers, contractors, and consultants of the responsible entity whose assigned
work duties include functions associated with the immunization of patients will have access to PhilaVax information.
VII. Data Quality
PhilaVax does not guarantee, but will use its best efforts to contribute to, the truth, accuracy or completeness of any
information provided under this agreement, including individual patient information. The provider is solely responsible
for exercising independent professional judgment in the use of such information. Likewise, the responsible entity will
utilize its best judgment in providing the most accurate and up to date information to PhilaVax.
VIII. Termination
This agreement may be terminated by PhilaVax at its discretion upon verication of any breach of the Responsible Entity
Security and Condentiality Agreement as outlined. Any violation of this agreement will be subject to revocation of access
privileges and may result in civil or criminal penalties for improper use and/or disclosure of health information.
Entity Enrollment Form
PhilaVax
November 2020 | [email protected]
Philadelphia Department of Public Health - Divison of Disease Control - Immunization Program
1101 Market St. Floor 12, Philadelphia, PA, 19107 | vax.phila.gov | [email protected]
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Type of Organization Represented:
Entity Representative Name (Please print)
Signature
Title
Date
Name of Organization
Mailing Address
City
Email Address
Phone Number Extension Fax Number
State Zip Code
Health System Private Clinic EMR Vendor Other:
I, the undersigned, as a representative of the above named responsible entity, have read and agree to abide by the Phila-
Vax Reponsible Entity Security and Condentiality Agreement.
Please fax this form to: (215) 238-6944
Or email to: PhilaV[email protected]
PDPH USE ONLY
Date Received:
Approved?:
Entered by:
Clinic Code:
