Eligibility Verification Portal (EVP) Access Form (PDF)

Texas Medicaid/CHIP Vendor Drug Program
Eligibility Verification Portal (EVP) Access Form
Registering
The pharmacy is required to designate an administrator in order for the Eligibility Verification Portal (EVP) Access Form
to be processed. This administrator will reset the passwords on the EVP. Individual user passwords will be emailed to the
administrator who will then forward the email to the appropriate user. It is the administrator’s responsibility to reset the
password if an employee leaves, thereby removing access to the EVP for that user. This EVP Access Form is required to
add new users.
Passwords
Xerox will assign a User ID and temporary password by email. The user will be prompted to change the
password the first time the user logs in. If the user forgets the password or wants to reset the password, then
click the “Forgot/Change Password” link on the EVP screen.
• Xerox will email a temporary password to the designated administrator, who will then forward the email
to the user making the request. The user will be required to change the password the next time he or she
attempts to access the EVP.
Access
The EVP is online at https://txpcra.acspbms.com/ACSPortal/login.jsp. From the dropdown box, select “Eligibility
Verification” and then enter your User ID and password. The EVP is accessible only through the Microsoft Internet
Explorer browser. The browser is available for free from Microsoft.com.
Instructions
Please complete all requested information. Return the form:
By fax:
866-780-2185
By email:
[email protected]
If you choose to send this document via email then be aware you may be sending
protected health information (PHI). Please electronically encrypt your information prior to sending.
Please direct all questions to the Xerox Technical Support and Interfaces Desk:
By phone:
888-701-1713
Rev. 10/2014
vdp_ecm_evpacs
Page 1 of 2
www.TxVendorDrug.com
Texas Medicaid/CHIP Vendor Drug Program
Eligibility Verification Portal (EVP) Access Form
Please identify if this form is:
Request for new access
Request for update to information on file
Classification (please identify):
Independent pharmacy
Chain pharmacy/corporate headquarters
(Check the section box, below, that is being updated.)
SECTION 1: PHARMACY PROVIDER INFORMATION
NPI Number (required):
Legal Name:
Provider DBA Name:
Business Address:
City, State, and ZIP:
Telephone:
Fax:
Email:
SECTION 2: EVP ADMINISTRATOR INFORMATION
Contact Name:
Contact Title:
Business Address:
City, State, and ZIP:
Telephone:
Fax:
Email:
SECTION 3: ADDITIONAL EVP USERS
First Name
Rev. 10/2014
vdp_ecm_evpacs
Last Name
Phone Number (If different from above)
Page 2 of 2
www.TxVendorDrug.com

Download Report