Enrollment Forms

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Forms

Name Number
Pharmacy Enrollment Instructions (May 2019) (PDF)  
Pharmacy Enrollment Application 1340
Pharmacy Provider Enrollment Agreement (PDF) 1341
Pharmacy Eligibility Verification Portal Access Form 1317
Pharmacy Electronic Remittance Advice Agreement 1316
Child Support Certification 1903
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts H2046
Certification Regarding Federal Lobbying H2047
Pharmacy Ownership Transfer Affidavit 1332
Direct Deposit Authorization (PDF) CPA 74-176
Application for Payee Identification Number (PDF) CPA AP-152

Delivery Sign

Enrolled pharmacies approved to offer no-cost delivery services to people eligible for Medicaid are eligible to receive the HHS delivery incentive. VDP-approved delivery pharmacies must display the HHSC-approved pharmacy delivery sign (PDF) in a prominent place within the store. Refer to the Enrollment (PDF) chapter of the Pharmacy Provider Procedure Manual for more information.

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