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