Texas Medicaid and CHIP Free Delivery Incentive Fee Attestation

Is your pharmacy registered with the Texas VDP to provide Free Delivery Services and receive the Delivery Incentive fee?

Yes No (will result in no incentive fee paid)

Does your pharmacy advertise to Medicaid and CHIP Members the availability of prescription delivery services at no charge?

Yes No

Does your pharmacy display the HHSC-approved delivery sign in a prominent place in the store (e.g., window, door)?

Yes No

Is the Delivery made to recipients in the same manner and degree as to the general public?

Yes No

Please Include a photo of the HHSC-approved delivery sign, showing the location, visible to members. Failure to return the photo with the attestation will exclude pharmacy from delivery incentive fee being reimbursed.

Name of Owner / Authorized Agent:

Pharmacy Name: NCPDP Number:

Full Name: Date:

TAC §355.8551(c)