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Washington Vaccine Association

Facilitating universal purchase of vaccines for all the children of Washington state

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Do you have sample forms I can look at?

You are here: Home / FAQs / Do you have sample forms I can look at?

August 4, 2020 By

DBA Form Sample (pdf)

Completed samples of the two forms required for the dosage-based assessment (DBA) process.

Electronic Form (pdf)

Crosswalk that shows the fields and data for the electronic form format as compared to paper CMS 1500 format.

Washington Vaccine Association Assessment Grid

Chart listing the dosage-based assessment charges for vaccines covered by the state’s Childhood Vaccine Program.

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WA Vaccine Association

Washington Vaccine Association
PO Box 94002
Seattle, WA 98124-9402
1-888-928-2224
888-928-2242
info@wavaccine.org

WVA Tax ID: 27-2251833
WVA NPI: 1699092718

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