Form 3 Cert state or local government Revised

Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau
OMB No. 0915-XXXX; Expiration Date: XX/XX/XXXX

OFFICE OF PHARMACY AFFAIRS (OPA)
CERTIFICATION OF CONTRACT BETWEEN PRIVATE, NON-PROFIT HOSPITAL AND
STATE/LOCAL GOVERNMENT TO PROVIDE HEALTH CARE SERVICES TO LOW INCOME
INDIVIDUALS
To demonstrate that the hospital meets the statutory definition of covered entity under section
340B(a)(4)(L)(i) as a private non-profit hospital which has a contract with a State or local
government to provide health care services to low income individuals, this certification must be
completed and signed by both parties.

____________________________________________________________________
Name of Hospital
____________________________________________________________________
City, State, Zip
Pursuant to the requirement of Section 340B of the Public Health Service Act
(42 U.S.C. 256b), I certify that a valid contract (please provide contract number or
identifier if applicable #_________) is currently in place between the private, non-profit
hospital named above, and the State or Local Government Entity named below, to
provide health care services to low income individuals who are not entitled to benefits
under Title XVIII of the Social Security Act or eligible for assistance under the State plan
of Title XIX of the Social Security Act. In addition, the authorizing official certifies that
when this contract is no longer valid, appropriate notice will be provided to the Office of
Pharmacy Affairs. The undersigned represents and confirms that he/she is fully
authorized to legally bind the covered entity and certifies that the contents of any
statement made or reflected in this document are truthful and accurate.
_______________________________________________
Signature of Hospital Authorizing Official Date
_______________________________________________
Name and Title of Authorizing Official (e.g., CEO, CFO, COO)
_______________________
Phone Number

______
Ext.

_______________

(please print or type)

____________________________
E-Mail Address

_______________________________________________
Signature of State or Local Government Official

_______________
Date

__________________________________________________
Name of State or Local Government Official (please print or type)
______________________________________________________________________
Title and Unit of Government
______________________________________________________________________
Address
_______________________
Phone Number

_________
Ext.

_____________________________
E-Mail Address

This registration form must be completed and submitted according to the established deadlines that are published on the OPA website (www.hrsa.gov/opa).
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The OMB control number for this project Is 0915-XXXX. Public burden is estimated to average XX minutes per respondent, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland 20857.