Form 340B-10b Certification of State/Local Contract

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 DISPROPORTIONATE SHARE HOSPITAL (DSH) AND STATE/LOCAL GOVERNMENT TO PROVIDE HEALTH CARE SERVICES TO LOW INCOME INDIVIDUALS

To meet the eligibility requirements for a private, non-profit DSH to buy discounted outpatient drugs under Section 340B of the Public Health Service Act, this certification must be completed and signed by both parties.

____________________________________________________________________

Name of Disproportionate Share Hospital

____________________________________________________________________

City, State, Zip

_______________________________________________ _______________

Signature & Title of Authorizing Official (CEO, CFO, COO) Date

_______________________________________________

Name of Authorizing Official (please print or type)

_______________________ ______ __­­­__________________________

Phone Number Ext. E-Mail Address

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 In addition, I certify that when this contract is no longer valid, appropriate notice will be provided to the Office of Pharmacy Affairs.

_____________________________________________________________________

Signature of State or Local Government Official

__________________________________________________ ________________

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

______________________________________________________________________

Title and Unit of Government

______________________________________________________________________

Address

_______________________ _________ _____________________________

Phone Number Ext. E-Mail Address

The quarterly deadlines for data submission to OPA are December 1 for the quarter beginning January 1; March 1 for the quarter beginning April 1; June 1 for the quarter beginning July 1; and September 1 for the quarter beginning October 1.

Submit original, signed form to: HRSA, Office of Pharmacy Affairs, 5600 Fishers Lane, Mail Stop 10C-03, Rockville, Maryland 20857

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.