Refer to the enrollment process to learn when HHSC requires these forms.
Application for Texas Identification Number
- HHS Form 4109
- txvendordrug.com/sites/default/files/docs/4109.pdf
- Usage: new enrollment, revalidation, change in ownership
Direct Deposit Authorization
- CPA 74-176
- txvendordrug.com/sites/default/files/docs/direct-deposit-authorization.pdf
- Usage: new enrollment, revalidation, change in ownership, change in banking information
Pharmacy Electronic Remittance Advice Agreement
Pharmacy Eligibility Verification Portal Access
Pharmacy Ownership Transfer Affidavit
- HHS Form 1332
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1332-pharmacy-ownership-transfer-affidavit
- Usage: change in ownership
CCP Prior Authorization Request Form
- Refer to the Comprehensive Care Program Enrollment section for instructions on using this form
- TMHP Form F00012
- tmhp.com/sites/default/files/provider-forms/pa-forms/F00012_CCP_Prior_Authorization_Request_Form.pdf
Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form
- Refer to the Durable Medical Equipment Provider Enrollment section for instructions on using this form
- TMHP Form F00030
- tmhp.com/sites/default/files/provider-forms/pa-forms/F00030_Home_Health_Title_XIX_DME_Medical_Supplies_Order_Form.pdf