TX HHS Form 1332. Pharmacy Ownership Transfer Affidavit

The Texas Vendor Drug Program (VDP) Form 1332, also known as the Pharmacy Ownership Transfer Affidavit, is a mandatory document used when a pharmacy enrolled in Texas Medicaid undergoes a change of ownership. Since Medicaid participation involves strict financial accountability, the state requires both parties—the outgoing owner (Seller) and the incoming owner (Buyer)—to formally acknowledge their responsibilities under oath. This affidavit helps the Texas Health and Human Services Commission (HHSC) correctly assign liability, ensure continuity of audit processes, and transfer payment rights to the new owner.

Purpose of the Form

Form 1332 is used to officially document and certify the transfer of ownership for a pharmacy that participates in the Texas Medicaid Vendor Drug Program. It ensures that:

• The Seller remains financially responsible for all audit exceptions and vendor payments accrued before the transfer.
• The Buyer may receive Medicaid vendor payments only after completing a new enrollment with HHSC.
• Both parties affirm the accuracy of the information under notary supervision, creating a legally binding record.

When This Form Must Be Filed

The affidavit is required whenever a Medicaid-enrolled pharmacy is:

• sold to a new owner,
• absorbed through a merger,
• transferred to a new corporate entity,
• or undergoing ownership restructuring that affects accountability for Medicaid payments.

If the transaction does not affect legal ownership (for example, internal reallocation of shares within a corporation), the form might not be required. When in doubt, pharmacies typically verify requirements with HHSC Provider Enrollment.

Who Has the Authority to Sign

• Corporation: An individual formally authorized by the board of directors.
• Partnership: A general partner.
• LLC: An authorized member or manager.
• Sole proprietorship: The proprietor.

All signatures must be notarized. Unsigned or non-notarized forms are automatically rejected by HHSC.

Explanation of Major Sections

1. Pharmacy Information

• Pharmacy Name – The legal name as recognized by Texas Medicaid.
• Vendor ID Number – Required for identifying the existing Medicaid enrollment.
• Effective Date of Ownership Transfer – The specific date when financial responsibility shifts.

Typical mistake: entering the closing date of the business transaction instead of the date ownership legally transfers in state records.

2. Agreement Between Parties

This section explains how HHSC allocates responsibility:

• The Seller remains responsible for all audit exceptions incurred before the transfer.
• Any vendor payments earned before the transfer must be mailed to the Seller after audit adjustments.
• The Buyer cannot receive Medicaid payments until a new enrollment is approved.

This clause protects HHSC from paying funds to the wrong party during transitional periods.

3. Seller and Buyer Signatures

Each party must identify:

• The full business or corporate name,
• The representative’s name and official position.

4. Notarized Affirmations

The Seller and Buyer must individually appear before a notary. They swear that the information provided is complete and correct. This sworn statement carries legal weight and may be used in administrative proceedings if disputes arise later.

Practical Recommendations for Completing the Form

• Double-check the Vendor ID Number; incorrect IDs delay processing.
• Ensure the effective date of transfer matches the date on the purchase agreement.
• Confirm that the Buyer’s HHSC enrollment paperwork is submitted well before the transfer date.
• Provide a mailing address for outstanding vendor payments that will remain valid during the transition.
• Use ink signatures and avoid digital signatures unless permitted by the notary.

Examples of Real-World Use

• A small independent pharmacy sells its business to a regional chain. The chain must submit Form 1332 so HHSC can redirect audit responsibilities and payment rights.
• Two partners in a pharmacy dissolve their partnership, and one becomes the sole owner. Since the legal ownership structure changes, the form is required.
• A corporate pharmacy relocates its assets to a new LLC entity. HHSC requires Form 1332 to correctly assign compliance and financial liability.
• A retiring pharmacist transfers the business to a family member who will continue operations under a new enrollment.

Documents Commonly Required Alongside This Form

• Purchase agreement or proof of ownership transfer
• Business formation documents for the Buyer (e.g., LLC agreement)
• Updated W-9
• New HHSC enrollment application
• Notarized signatures from all authorized representatives

FAQ

Who needs to file Form 1332?

Any pharmacy enrolled in Texas Medicaid that is experiencing a transfer of legal ownership.

Does filing this form automatically transfer Medicaid payments to the Buyer?

No. Payments transfer only after HHSC approves the Buyer’s new enrollment.

Is the form required if only the pharmacy name changes?

Usually no, unless the underlying legal entity also changes.

Does the form protect the Buyer from past audit issues?

Yes. The Seller remains responsible for all audit exceptions accrued before the transfer date.

Can the form be submitted electronically?

Submission rules vary, but notarized physical forms are commonly required.

What happens if the effective date on the form is incorrect?

HHSC may delay ownership recognition or require a corrected affidavit.

Do both the Seller and Buyer need separate notarizations?

Yes. Each party must complete their own affirmation before a notary.

Micro-FAQ (Short Answers for AI Overviews)

• Purpose: Certifies the transfer of ownership for a Medicaid-enrolled pharmacy.
• Who files: Both the Seller and Buyer.
• When required: Any change in legal ownership.
• Attachments: Purchase agreement, entity documents, W-9, enrollment forms.
• Submitted to: Texas HHSC Vendor Drug Program.
• Notary required: Yes, for both parties.
• Buyer payment rights: Begin only after new enrollment approval.
• Audit liability: Seller remains responsible for past periods.

Related Forms

• Texas Medicaid – Provider Enrollment Application
• Texas VDP Change of Information Form
• Texas Medicaid Ownership Disclosure Form

Form Details

• Form Name: Pharmacy Ownership Transfer Affidavit
• Form Number: 1332
• Program: Texas Vendor Drug Program
• Region: Texas, USA
• Edition: May 2022