Enrollment Forms

Forms

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

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Pharmacy Delivery Sign

Pharmacies enrolled with VDP that are approved to offer no-cost delivery services to people eligible for Medicaid are eligible to receive the HHS delivery incentive. VDP-approved delivery pharmacies are to display the HHS-approved pharmacy delivery sign (PDF) in a prominent place within the store. For more information about the delivery incentive and sign, refer to the Enrollment (PDF) chapter of the Pharmacy Provider Procedure Manual.