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Form 1317, Pharmacy Eligibility Verification Portal Access Form-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by identifying the reason for form submission. Choose between 'Request for new access' or 'Request for update to information on file'.
- Next, select your pharmacy classification by checking either 'Independent pharmacy' or 'Chain pharmacy/corporate headquarters'.
- Fill out the Pharmacy Provider Information section. Include the Legal Name of Provider, Business Address (Street, City, State and ZIP Code), DBA Name, Area Code and Telephone No., Area Code and Fax No., and Email.
- Complete the EVP Administrative Information section with the Name and Title of Administrator, along with their contact details including Area Code and Telephone No., Business Address, Area Code and Fax No., and Email.
- If applicable, provide Additional EVP User Information by entering First Name, Last Name, and Phone Number if different from above.
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Related links
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Processes Change of Name, Leave of Absence and other official forms. Processes transfer credit requests. Verifies enrollment status for insurance,Read more