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 | CPA 74-176 |
| Application for Payee Identification Number | CPA AP-152 |
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.