Enrollment Forms

March 31: Medicaid to Allow Expedited Pharmacy Enrollment Beginning April 1

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Forms

Pharmacy Enrollment Instructions (Nov. 2019) (PDF)

Name	Number
Temporary Pharmacy Agreement (PDF)	1350
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

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.