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.