Pharmacies enroll using the Texas Medicaid and Healthcare Partnership (TMHP) Provider Enrollment and Management System (PEMS). Refer to the TMHP Provider Enrollment for instructions. Change in ownership requests are not currently processed through PEMS. Refer to tmhp.com for instructions on submitting requests to TMHP.
The information below each form identifies the action when pharmacy staff must submit the form.
- Pharmacy Enrollment Application (HHSC Form 1340)
- Usage: change in ownership
- Pharmacy Enrollment Agreement (HHS Form 1341)
- Usage: change in ownership
- Pharmacy Eligibility Verification Portal Access Form (HHS Form 1317)
- Usage: new enrollment, revalidation, change in ownership
- Pharmacy Electronic Remittance Advice Agreement (HHS Form 1316)
- Usage: new enrollment, revalidation, change in ownership
- Pharmacy Ownership Transfer Affidavit (HHS Form 1332)
- Usage: change in ownership
- Direct Deposit Authorization (CPA Form 74-176)
- Usage: new enrollment, revalidation, change in ownership, change in banking information
- Application for Payee Identification Number (CPA AP-152)
- Usage: new enrollment, revalidation, change in ownership