340B-10c Certification of Non GPO

D epartment 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 REGARDING NON-PARTICIPATION BY DISPROPORTIONATE SHARE HOSPITAL (DSH) IN A GROUP PURCHASING ORGANIZATION (GPO)

To meet the eligibility requirements for a disproportionate share hospital (DSH) to buy discounted outpatient drugs under Section 340B of the Public Health Service Act, this certification must be signed.

   

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Name of Disproportionate Share Hospital

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Hospital Address

________________________________________________________________

City, State, Zip

Once the above hospital has received written confirmation from the OPA that it has been accepted into the 340B Program, and is listed on the OPA database of 340B covered entities, I certify that this hospital will not participate in a group purchasing organization or group purchasing arrangement for covered outpatient drugs as of the date of this listing on the OPA database.
 

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Signature of Authorizing Official Date

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Printed Name of Authorizing Official and Title

_________________________________________________________________

Address

_________________________________________________________________

City, State, Zip

_______________________ Ext._____________ 

Phone Number

____________________________________________________________________

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.