Pharmacy Enrollment Forms
Refer to the enrollment process to learn when HHSC requires these forms. Refer to the Comprehensive Care Program Enrollment section for instructions on using TMHP Form F00012. Refer to the Durable Medical Equipment Provider Enrollment section for instructions on using TMHP Form F00030.
| Form Name | Form Number |
|---|---|
| Application for Texas Identification Number (PDF) | HHS Form 4109 |
| Direct Deposit Authorization (PDF) | CPA 74-176 |
| Pharmacy Ownership Transfer Affidavit (PDF) | HHS Form 1332 |
| TMHP Form F00012 | |
Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form (PDF) | TMHP Form F00030 |