Form 1 340B Registration-DSH Revised

OFFICE OF PHARMACY AFFAIRS (OPA)
340B PROGRAM REGISTRATION FOR DISPROPORTIONATE SHARE HOSPITALS
To meet the eligibility requirements for a disproportionate share hospital to participate and be listed
as an eligible covered entity under Section 340B(a)(4)(L) of the Public Health Service Act, this
registration form must be completed and submitted according to the established deadlines that are
published on the OPA website (www.hrsa.gov/opa).
A completed registration package must include:
(1) This Basic registration information and compliance certification;
(2) A copy of Worksheet E, Part A from the latest filed Medicare cost report (for the DSH adjustment
percentage in II, A, below.);
(3) A copy of Worksheet S-2 to demonstrate ownership type, and depending upon the hospital type
the additional documentation described in II, B, below); and
(4) Certification of non-participation in a Group Purchasing Organization.
All documentation described in 1-4 above is required to constitute a complete registration package.
The entire package must be submitted on the same day to be considered complete. Incomplete
packages will not be processed.

I. Hospital Information:
Hospital Name: _______________________________________________________________________
_______________________________________________________________________
Medicare Provider Number: ________________
Hospital Street Address: ______________________________________________________________
__________________________________________________________________________________
City: _______________________________________________ State: _________ ZIP: ___________
Hospital Billing Address (if different): _____________________________________________________
__________________________________________________________________________________
City: _______________________________________________ State: _________ ZIP: ___________

Hospital Shipping Address (if different): ___________________________________________________
__________________________________________________________________________________
City: _______________________________________________ State: _________ ZIP: ___________

II. Eligibility Criteria
A. Disproportionate Share Adjustment Percentage: ______% based on
Medicare Cost Reporting Period: ___/___ - ___/___
B. Type of Hospital

a) If Owned or Operated by State or Local Government, check here 
(Submit supporting documentation to verify State/Local Government ownership or operation). Please refer to the
Office of Pharmacy Affairs website for a description and examples of acceptable documentation.
b) If a Private, Non-Profit Hospital with State/Local Government Contract, check here 
(You must complete and attach State/Local Government Certification form
(ftp://ftp.hrsa.gov/bphc/pdf/opa/DSHGovtCert.pdf) on the same day the registration form is submitted to the Office

of Pharmacy Affairs. Please refer to the Office of Pharmacy Affairs website for a description and examples of
acceptable documentation.)

c) If a Public or Private Non-Profit Hospital Formally Granted Governmental Powers, check here 
(Submit supporting documentation to verify formal delegation of power to hospital by State/Local Government).
Please refer to the Office of Pharmacy Affairs website for a description and examples of acceptable
documentation.

III. Medicaid Billing Information: You must answer the following question regarding Medicaid billing.
Will your entity bill Medicaid for drugs purchased through the 340B Drug Pricing Program?
Yes 
No 
If “Yes,” please provide the Pharmacy/Clinic Medicaid Provider Number(s) and/or National Provider Identifier(s)
(NPI) used to bill Medicaid for 340B drugs (please include the number(s) and State):
Medicaid Provider Number(s) _______________________ and/or_____________________________
National Provider Identifier(s) _______________________and/or______________________________
If your entity bills Medicaid for 340B drugs that may be subject to a payment of a Medicaid rebate to a state, you
must submit to OPA the pharmacy/clinic Medicaid number and/or NPI which is used to bill Medicaid for
outpatient drugs. If you are unsure of your Medicaid billing number and/or NPI, please check with your State
Medicaid agency. It is important that your Medicaid billing status is accurate in the 340B database Medicaid
Exclusion File to prevent Medicaid rebates on drugs that were purchased under the 340B Drug Pricing Program
and to ensure that the state Medicaid Agency has accurate information for those drugs not purchased under the
340B Program. You must notify OPA prior to any change in your Medicaid billing status.
For more information, go to: http://www.hrsa.gov/opa/medicaidexclusion.htm

IV. Designated 340B Contact and Authorizing Official Information:
340B Contact
Name: _________________________________________________________________
Title: ______________________________________________________________________________
Phone: _______________________

Ext. __________

Fax: _____________

Email Address: ______________________________________________________________________
Covered Entity Authorizing Official (Must be authorized to legally bind covered entity (e.g., CEO, CFO, COO)
Name: _________________________________________________________________
Title: ______________________________________________________________________________
Phone: _______________________

Ext. __________

Fax: _____________

Email Address: ______________________________________________________________________

2

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.

Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau
OMB No. 0915-XXXX; Expiration Date: XX/XX/XXXX

V. Signed Agreement:
The undersigned represents and confirms 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.
The undersigned further acknowledges the 340B covered entity’s responsibility to abide by the following:
As an Authorized Official, I certify on behalf of the covered entity that:
(1) all information listed on the 340B Program database for the covered entity will be complete, accurate, and
correct;
(2) the covered entity will meet all 340B Program eligibility requirements, including section 340B(a)(4)(L)(iii) –
the Group Purchasing Organization prohibition - which ensures that the covered entity hospital does not obtain
covered outpatient drugs through a group purchasing organization or other group purchasing arrangement;
(3) the covered entity will comply with all requirements and restrictions of Section 340B of the Public Health
Service Act and any accompanying regulations or guidelines including, but not limited to, the prohibition against
duplicate discounts/rebates under Medicaid, and the prohibition against transferring drugs purchased under
340B to anyone other than a patient of the entity;
(4) the covered entity will maintain auditable records demonstrating compliance with the requirements described
in paragraph (3) above;
(5) the covered entity has systems/mechanisms in place to ensure ongoing compliance with the requirements
described in (3) above;
(6) if the covered entity uses contract pharmacy services, that the contract pharmacy arrangement will be
performed in accordance with OPA requirements and guidelines including, but not limited to, that the covered
entity obtains sufficient information from the contractor to ensure compliance with applicable policy and legal
requirements, and the hospital has utilized an appropriate methodology to ensure compliance (e.g., through an
independent audit or other mechanism);
(7) the covered entity acknowledges its responsibility to contact OPA as soon as reasonably possible if there is
any material change in 340B eligibility and/or material breach by the covered entity of any of the foregoing; and
(8) the covered entity acknowledges that if there is a breach of the requirements described in paragraph (3) that
the covered entity may be liable to the manufacturer of the covered outpatient drug that is the subject of the
violation, and, depending upon the circumstances, may be subject to the payment of interest and/or removal
from the list of eligible 340B entities.

Signature of Authorizing Official:

Date:

__________________________________________________________________________________

3