4 Public OWNERSHIP Revised

Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau

OFFICE OF PHARMACY AFFAIRS (OPA)
HOSPITAL CERTIFICATION OF OWNERSHIP/OPERATION
BY A UNIT OF STATE/LOCAL GOVERNMENT
In order to meet the eligibility requirement (Section 340B(a)(4)(L)(i)) of
ownership/operation by a unit of state/local government this certification must be
completed and signed by a representative from both parties specified below.
____________________________________________________________________________

Name of Hospital
____________________________________________________________________________

Street Address, City, State, Zip
I certify that the aforementioned hospital organization is owned and/or operated
by a unit of the State or local government. (Please check the appropriate box below)
Owned

Operated

Both

________________________________________________________________
Signature of State or Local Government Official

Date

______________________________________________________________________________________

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

Title and Unit of Government
__________________________

_______

____________________________

Phone Number

Ext.

E-Mail Address

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 the ownership and/or operating status identified above is
currently valid, and agree to inform the Office of Pharmacy Affairs of any
material change as soon as reasonably possible.
______________________________________________________________________________________

Signature of Hospital Authorizing Official

Date

______________________________________________________________________________________
Name & Title of Hospital Authorizing Official (e.g.: CEO, CFO, COO) (Please print or type)

__________________________

_______

____________________________

Phone Number

Ext.

E-Mail Address

This registration form must be completed and submitted according to the established deadlines that are published on the OPA
website (www.hrsa.gov/opa).
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