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Provider Forms

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Required Forms for Your COVID-19 Vaccine Appointment

provider vaccine forms

Eligible health care workers can now schedule COVID-19 vaccines at ACPNY vaccine locations throughout the city

Before your appointment for a COVID-19 vaccine, please review and complete the following forms:


You will need to complete the NYS Eligibility Form in order to get vaccinated. You must show completion of this form when you arrive for your appointment. In addition, you will need to bring proof of employment, such as an employee ID card, a letter from your employer or affiliated organization, or a recent pay stub.


Read and complete the COVID-19 vaccine consent form. Bring the completed form with you on the day of your appointment.


Review the Moderna Vaccine EUA Fact Sheet for Patients.