Contracted Pharmacy Services Registration and Recertifications

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

Documents and Forms

Document Name Document Type
Form 3.1 Contracted Pharmacy Services Registration and Recertifications Form
3.1 Contract Pharmacy Registration.pdf Contract Pharmacy Registration.pdf Form
3.1 Contract Pharmacy Registration.pdf Contract Pharmacy Registration.pdf Form
3.2 Contract Pharmacy Termination.pdf Contract Pharmacy Termination.pdf Form
3.2 Contract Pharmacy Termination.pdf Contract Pharmacy Termination.pdf Form

Information Collection (IC) Details

IC Title:	Contracted Pharmacy Services Registration and Recertifications	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3.1	Contract Pharmacy Registration.pdf	Contract Pharmacy Registration.pdf		Yes	Yes	Fillable Fileable
Form	3.2	Contract Pharmacy Termination.pdf	Contract Pharmacy Termination.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,446	Number of Respondents for Small Entity: 1,200

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	37,906	15,378	22,528
Annual IC Time Burden (Hours)	37,906	15,378	22,528
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.