2 Cert state or local government-Revised

Enrollment and Re-Certification of Entities in the 340B Drug Pricing Program and Collection of Manufacturer Data to Verify 340B Drug Pricing Program Ceiling Price Calculations

Cert state or local government-Revised

340B Program Registrations amp; Certifications for Children's Hospitals

OMB: 0915-0327

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Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau

OMB No. 0915-0327; Expiration Date: XX/XX/20XX


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


This certification must be completed and signed by representatives from the parties specified below acknowledging the hospital meets the eligibility requirement in section 340B(a)(4)(L)(i) of the Public Health Service Act regarding a private non-profit hospital which has a contract with a State or local government to provide health care services to low income individuals.

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Name of Hospital



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Street Address, City, State, Zip


Pursuant to section 340B(a)(4)(L)(i) of the Public Health Service Act, the Hospital Authorizing Official certifies that a valid contract (please provide contract number or identifier below 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. The Hospital Authorizing Official certifies that immediate notice will be provided to the Office of Pharmacy Affairs when this contract is no longer valid. The Hospital Authorizing Official certifies 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.



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Hospital Authorizing Official Signature Date


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Name and Title of Authorizing Official (e.g., CEO, CFO, COO)


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Phone Number Ext. E-Mail Address



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State or Local Government Official Signature Date


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Name of State or Local Government Official (please print or type)


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Title and Unit of Government


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Address


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Phone Number Ext. E-Mail Address



Contract Number or Identifier, if applicable: __________________


Contract start date: __ / __ / ____ Contract end date: __ / __ / ____


    • Check here if the entity’s contract is valid until cancelled.


This registration form must be completed and submitted according to the established deadlines that are published on the OPA website (www.hrsa.gov/opa).



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDepartment of Health and Human Services Health Resources and Services Administration HealthCare Systems Bureau
AuthorHRSA
File Modified0000-00-00
File Created2021-01-24

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