Effective Date: 
1/2018

Documents

Instructions

Updated: 1/2018

 

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 when an enrolled pharmacy changes ownership.  The completed form must contain both the seller’s and buyer’s information and be notarized.

 

Transmittal

  • Mail:

VDP (MC-2250)
Texas Health and Human Services
4900 North Lamar Blvd.
Austin, TX 78751

  • Email:

MCDPharmacyContractManage@hhsc.state.tx.us

 

Questions

Questions about this form should be directed to the Vendor Drug Program by email at MCDPharmacyContractManage@hhsc.state.tx.us.

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