Instructions
- Pharmacy Enrollment Instructions (Nov. 2019) (PDF)
- Pharmacy Provider Revalidation Frequently Asked Questions (PDF)
Forms
The information below each form identifies the action when pharmacy staff must submit the form.
- Temporary Pharmacy Agreement (PDF) (HHS Form 1350)
- New enrollment
- Revalidation
- Change in ownership
- Pharmacy Enrollment Application (HHSC Form 1340)
- New enrollment
- Revalidation
- Change in ownership
- Pharmacy Enrollment Agreement (HHS Form 1341)
- New enrollment
- Revalidation
- Change in ownership
- Pharmacy Eligibility Verification Portal Access Form (HHS Form 1317)
- New enrollment
- Revalidation
- Change in ownership
- Pharmacy Electronic Remittance Advice Agreement (HHS Form 1316)
- New enrollment
- Revalidation
- Change in ownership
- Child Support Certification (HHS Form 1903)
- New enrollment
- Revalidation
- Change in ownership
- Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts Certification (HHS Form 1400)
- New enrollment
- Revalidation
- Change in ownership
- Federal Lobbying Certification (HHS Form 1401)
- New enrollment
- Revalidation
- Change in ownership
- Pharmacy Ownership Transfer Affidavit (HHS Form 1332)
- Change in ownership
- Direct Deposit Authorization (PDF) (CPA Form 74-176)
- New enrollment
- Revalidation
- Change in ownership
- Application for Payee Identification Number (PDF) (CPA AP-152)
- New enrollment
- Revalidation
- Change in ownership
Delivery Sign
Medicaid-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 chapter of the Pharmacy Provider Procedure Manual for more information.