Forms
| Name | Number |
|---|---|
| Pharmacy Enrollment Application | 1340 |
| Pharmacy Enrollment Agreement | 1341 |
| Pharmacy Eligibility Verification Portal Access Form | 1317 |
| Pharmacy Electronic Remittance Advice Agreement | 1316 |
| Child Support Certification | 1903 |
Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts Certification
|
1400 |
Federal Lobbying Certification
|
1401 |
| Pharmacy Ownership Transfer Affidavit | 1332 |
| Direct Deposit Authorization (PDF) | CPA 74-176 |
| Application for Payee Identification Number (PDF) | CPA AP-152 |
Note: Having Trouble Viewing or Downloading a Form?
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.