3 GPOform Revised

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 REGARDING NON-PARTICIPATION BY A COVERED ENTITY HOSPITAL
IN A GROUP PURCHASING ORGANIZATION (GPO)
To demonstrate that the hospital meets the statutory definition of covered entity under section
340B(a)(4)(L)(iii) that requires that the hospital does not obtain covered outpatient drugs through
a group purchasing organization or other group purchasing arrangement, this certification must
be signed. This is a requirement for Disproportionate Share Hospitals, Children’s Hospitals, and
Free Standing Cancer Hospitals.

________________________________________________________________
Name of Hospital
________________________________________________________________
Hospital Address
________________________________________________________________
City, State, Zip
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. 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. If drugs are purchased using a
GPO for covered outpatient drugs while participating in the 340B Program, the covered
entity understands that this violates program eligibility requirements and that the
covered entity is obligated to inform OPA and may be required to repay manufacturers
for the 340B discount received.
________________________________________________________________
Signature of Authorizing Official
Date
_________________________________________________________________
Printed Name of Authorizing Official and Title
_________________________________________________________________
Address
_________________________________________________________________
City, State, Zip
_______________________
Phone Number

Ext._____________

____________________________________________________________________
E-Mail Address
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.