Enrollment Forms

Forms

• Texas Medicaid Pharmacy Provider Enrollment Application (PDF)
  • Enrollment application instructions (PDF)
  • Enrollment frequently asked questions (PDF)
• Texas Medicaid Pharmacy Provider Enrollment Agreement (PDF)
• Direct Deposit Authorization (Form 74-176)
  • from comptroller.texas.gov.
• Application for Payee Identification Number (PDF) (Form AP-152)
  • from comptroller.texas.gov.
• Vendor Information Form (PDF)
• Child Support Certification Form (PDF)
• Debarment Certification Form (PDF)
• Lobbying Certification Form (PDF)
• Ownership Transfer Affidavit (PDF)
• Pharmacy Eligibility Verification Portal Access Form (PDF)
• Pharmacy Electronic Remittance Advise Agreement Form (PDF)

Application Fee

HHSC requires application fees for pharmacies enrolling in Texas Medicaid in accordance with federal guidelines.  The Centers for Medicare and Medicaid Services (CMS) issued new guidance to HHSC on December 30, 2015, stating that any enrolled pharmacy location that paid an application fee in Medicare does not have to pay the application fee to a state Medicaid agency. Pharmacies that paid the fee to Medicare and to Texas Medicaid may be eligible for a refund of the fee from HHSC.

• For applications submitted between January 1, 2017, and December 31, 2017, inclusive, the fee is $560.00.

Contact

• Pharmacy Enrollment and Maintenance