Pharmacy Provider Enrollment
Forms and resources required for pharmacies enrolling into the Medicaid/CHIP Vendor Drug Program.
- VDP Pharmacy Provider Enrollment Application (PDF)
- VDP Pharmacy Provider Enrollment Agreement (PDF)
- Direct Deposit Authorization (Form 74-176) (from comptroller.texas.gov)
- Application for Payee Identification Number (AP-152) (from comptroller.texas.gov)
- Vendor Information Form (PDF)
- Child Support Certification Form (PDF)
- Debarment Certification Form (PDF)
- Lobbying Certification Form (PDF)
- VDP Eligibility Verification Portal Access Form (PDF)
- VDP Electronic Remittance Advice Authorization Agreement Form (PDF)
- Ownership Transfer Affidavit (PDF)
Pharmacy Application Fee Refunds
HHSC requires application fees for pharmacies enrolling in the Vendor Drug Program in accordance with federal guidelines. The Centers for Medicare and Medicaid Services (CMS) issued new guidance to HHSC on December 30, 2015, stating that any enrolled pharmacy location that paid an application fee in Medicare does not have to pay the application fee to a state Medicaid agency. Pharmacies that paid the fee to Medicare and to Texas Medicaid may be eligible for a refund of the fee from HHSC.
- HHSC contact for questions and completed application packets.