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Effective Date: 
1/2020

Documents

 

Instructions

Updated: 4/2021

 

Purpose

Pharmacy providers already enrolled with Texas Medicaid utilize this form to notify HHSC of change in ownership.

 

Detailed Instructions

The form must be submitted in conjunction with the VDP Pharmacy Enrollment Application (Form 1340) when an enrolled pharmacy changes ownership. The completed form must contain both the seller’s and buyer’s notarized signatures.

 

Transmittal

Email:  

providerenrollment@tmhp.com

 

Questions

Refer comments or questions about this form to the Texas Medicaid & Healthcare Partnership at providerenrollment@tmhp.com.