Enrollment Forms

Instructions

• Pharmacy Enrollment Instructions (Nov. 2019) (PDF)

Forms

The information below each form identifies the action when pharmacy staff must submit the form.

• Temporary Pharmacy Agreement (PDF) (HHS Form 1350)
  • New enrollment
  • Revalidation
  • Change in ownership
• Pharmacy Enrollment Application (HHSC Form 1340)
  • New enrollment
  • Revalidation
  • Change in ownership
• Pharmacy Enrollment Agreement (HHS Form 1341)
  • New enrollment
  • Revalidation
  • Change in ownership
• Pharmacy Eligibility Verification Portal Access Form (HHS Form 1317)
  • New enrollment
  • Revalidation
  • Change in ownership
• Pharmacy Electronic Remittance Advice Agreement (HHS Form 1316)
  • New enrollment
  • Revalidation
  • Change in ownership
• Child Support Certification (HHS Form 1903)
  • New enrollment
  • Revalidation
  • Change in ownership
• Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts Certification (HHS Form 1400)
  • New enrollment
  • Revalidation
  • Change in ownership
• Federal Lobbying Certification (HHS Form 1401)
  • New enrollment
  • Revalidation
  • Change in ownership
• Pharmacy Ownership Transfer Affidavit (HHS Form 1332)
  • Change in ownership
• Direct Deposit Authorization (PDF) (CPA Form 74-176)
  • New enrollment
  • Revalidation
  • Change in ownership
• Application for Payee Identification Number (PDF) (CPA AP-152)
  • New enrollment
  • Revalidation
  • Change in ownership

Delivery Sign

Medicaid-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 chapter of the Pharmacy Provider Procedure Manual for more information.