|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|
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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.