Form 1332, Pharmacy Ownership Transfer Affidavit

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Effective Date
05/2022
1332.pdf (114.63 KB)

Instructions

Updated: 05/2022

Purpose

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

Detailed Instructions

Pharmacies must submit the form to Texas Medicaid & Healthcare Partnership (TMHP) through the Provider Enrollment and Management System (PEMS) when an enrolled pharmacy changes ownership. The completed form must contain both the seller’s and buyer’s notarized signatures.

Transmittal

Upload the form to PEMS during the change of ownership process.

Questions

Refer comments or questions about this form to the TMHP at provider.relations@tmhp.com or call 800-925-9126.