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Florida SHOTS is...
a centralized database for recording and tracking childhood immunizations as authorized by s. 381.003, F.S.
Completion of this agreement according to the following conditions and instructions is required for authorized
access to Florida Shots.
AGREEMENT AND UNDERSTANDING
PLEASE READ CAREFULLY. As a CONDITION for enrolling in the Florida State Health Online Tracking
System, AUTHORIZED USERS AGREE TO:
1.
Use the database to register and record immunization information for children currently receiving vaccinations
under their care.
2.
Comply with parent or legal guardian’s request not to participate in Florida SHOTS by providing DH Form 1478,
Florida SHOTS Notification and Opt Out Form to parents, or referring parents to the Department of Health Bureau
of Epidemiology Immunization Section.
3.
Allow parents to review information in their child's immunization record and correct data errors.
4.
Notify Florida SHOTS personnel immediately in the event of medical license suspension or revocation.
5.
Enter accurate current and historical vaccination data in Florida SHOTS at the time of vaccine administration.
6.
Accept and abide by all relevant state statutes concerning medical record confidentiality and Florida SHOTS
access.
7.
Ensure that facility staff accessing Florida SHOTS using the health care provider user name and password adhere
to all laws and regulations pertaining to use and access.
8.
Contact Florida SHOTS to request new user IDs and passwords when necessary to prevent breaches of
confidentiality.
9.
Safeguard user IDs and passwords against unauthorized use and assume responsibility for staff access to Florida
SHOTS using the licensed provider's authorization.
In addition, for all authorized users of Florida SHOTS, it is UNDERSTOOD that:
1.
Authorized licensed providers may assign staff access to Florida SHOTS and are solely responsible for managing
such access.
2.
Any authorized user can view the immunization information in the system for any patient in the system who is under
their care, but can only modify vaccination information they provided.
3.
The provider agrees to be solely liable and hold the Department of Health harmless for any breaches of
confidentiality by the provider, or the provider’s employees or agents.
Complete the form according to the following instructions:
INSTRUCTIONS:
SECTION I – Licensed Health Care Provider Information
1.
Provide the name of health care providers licensed under Chapters 458, 459 or 464, F.S., and current medical
license number. Only health care providers licensed under the statutes above may be issued user IDs and
passwords for immunization registry use.
2.
The licensed health care provider must sign in the space provided.
3.
Provide a contact name and telephone number in the event that Florida SHOTS personnel have questions
regarding this agreement.
4.
This agreement will be effective two years from the date of approval, at which time a renewal agreement is
required.
SECTION II – Provider Practice Facility Information
Fill out all spaces for each facility where the licensed provider practices and requests access to Florida
SHOTS. Access at each facility will be through the provider's same user ID and password.
SECTION III – Agreement Submission - If you have any questions regarding completion of the form or
about Florida SHOTS, please call (877) 888-7468 (SHOT).
Authorized Private Provider User Agreement
For Access to Florida SHOTS
(Florida State Health Online Tracking System)
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