Form 1 340B Participatant Change Request Revised

340B PARTICIPANT CHANGE REQUEST
Change Request with tabs for each section that can be modified.

Covered Entity Details section is default view.

Covered Entity Details section in edit view.

Covered Entity Address section.

Covered Entity Address section in edit view.

Medicaid Billing Information section in view.

Medicaid Billing Information in edit view.

Contact Information section in view.

Contact Information section in edit view.

Comments textbox (Optional)

Authorize and Submit screen – verbiage to be provided by OPA.