Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
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Pharmacy providers already enrolled with Texas Medicaid utilize this form to notify HHSC of change in ownership.
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.
Vendor Drug Program (Mail Code 2250)
Texas Health and Human Services Commission
4900 North Lamar Blvd.
Austin, TX 78751
Questions about this form should be directed to the Vendor Drug Program by email.