Forms
| Form Name | Form Number |
|---|---|
| Pharmacy Provider Enrollment Application (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 |
Note: Each browser has its own settings to control how PDFs open from a web page. If a form does not display in your browser you will need to download the file to your computer to complete.
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.