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Effective Date: 
1/2018

Documents

Instructions

Updated: 4/2019

 

Purpose

Pharmacy providers already enrolled with Texas Medicaid utilize the Ownership Transfer Affidavit to notify the state of change a in pharmacy ownership.

 

Detailed Instructions

The Pharmacy Ownership Transfer Affidavit 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 information and be notarized.

 

Transmittal

Mail:    Vendor Drug Program (MC-2250)
            Texas Health and Human Services 4900 North Lamar Blvd.
            Austin, TX 78751

Email:  vdp-enrollment@hhsc.state.tx.us

 

Questions

Questions about this form should be directed to the Vendor Drug Program by email.