Enrollment Forms

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Forms

Name	Number	When Required
Temporary Pharmacy Agreement (PDF)	1350	New enrollment Revalidation Change in ownership
Pharmacy Enrollment Application	1340	New enrollment Revalidation Change in ownership
Pharmacy Enrollment Agreement	1341	New enrollment Revalidation Change in ownership
Pharmacy Eligibility Verification Portal Access Form	1317	New enrollment Revalidation Change in ownership
Pharmacy Electronic Remittance Advice Agreement	1316	New enrollment Revalidation Change in ownership
Child Support Certification	1903`	New enrollment Revalidation Change in ownership
Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts Certification	1400	New enrollment Revalidation Change in ownership
Federal Lobbying Certification	1401	New enrollment Revalidation Change in ownership
Pharmacy Ownership Transfer Affidavit	1332	Change in ownership
Direct Deposit Authorization (PDF)	74-176	New enrollment Revalidation Change in ownership
Application for Payee Identification Number (PDF)	AP-152	New enrollment Revalidation Change in ownership

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.