3.2 Contract Pharmacy Termination

Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau
OMB No. 0915-0327

340B Contract Pharmacy Termination
Active Contract for 340B ID - Covered Entity Type
Terminate
Please review the list of active contract pharmacies for this entity. If you want to request a contract termination, select the
appropriate contract(s), requested terminated date(s) and termination reason(s).
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 0915-0327. Public
reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing
instructions, searching existing data sources, 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 14N-39, Rockville, Maryland, 20857.
Note: If you are the Primary Contact (PC), your Covered Entity’s Authorizing Official (AO) will be notified and will have 15 days to
approve or reject the proposed contract pharmacy termination. If that Authorizing Official fails to respond, the contract pharmacy
will remain active in 340B OPAIS.
Termination Date: The termination date is the date the agreement ends between the covered entity and contract pharmacy. The
covered entity is responsible for reporting an accurate termination date for each contract pharmacy arrangement. It is expected
that 340B activity has ceased or will cease on the termination date requested.
Pharmacy
City
State
Start Date
Term Date _________________________________________________
Term Reason
Select a Termination Reason
• Business decision by covered entity and/or pharmacy
• Pharmacy closed
• Agreement registered in error
• Ownership change
• Covered Entity Terminated
• CE terminated due to audit finding

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 0915-0327. Public reporting burden for this collection of information is
estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, 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 14N136B, Rockville, Maryland, 20857.