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OPA 340B Database - (v5.2.2.2 - UAT)

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Covered Entity Details
340B ID:

CAH999999-99

Entity Name: TEST MEDICAL CENTER
Entity Sub-Division Name:
Medicare Provider Number: 999999

Entity Type: Critical Access Hospital
Grant Number:

Covered Entity Address
Main Address (PO Box Not Allowed)
1 HOSPITAL DRIVE
TEST, AL 99999
Billing Address Same as Main
Shipping Address Same as Main

Covered Entity Date Information
Continue Undo
Registration Date:
Participating Approval Date

8/17/2012

Participating Start Date:
Termination Reason:
Termination Date:
The date the entity became ineligible:
Last date that 340B drugs were or will be
purchased under this 340B ID:
Termination Comments:

Qualification Information

Qualifying information for outpatient facilities (child sites) will be automatically carried over from the main hospital record; please email us at [email protected] if you need
to report an independent DSH adjustment percentage, cost reporting period or ownership classification for a particular site. Organizations with DSH percentages below applicable thresholds must
decertify the parent hospital and ALL associated outpatient facilities.

Entity is a Critical Access Hospital defined by section 1820(c)(2) of the Social Security Act, and this status is recognized by CMS.
Hospital Classification: Owned or Operated by State or Local Government

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OPA 340B Database - (v5.2.2.2 - UAT)

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Medicaid Billing
Medicaid Billing Information
You must answer the following question regarding Medicaid Billing:
Will you bill Medicaid for drugs purchased at 340B drug price?

Yes

No

Orphan Drug Exclusion
340B hospitals subject to the orphan drug exclusion (i.e., critical access hospitals, free-standing cancer hospitals, sole community hospitals and rural referral centers) are responsible for
ensuring that any orphan drugs purchased through the 340B Program are not transferred, prescribed, sold, or otherwise used for the rare condition or disease for which the orphan drugs are
designated under section 526 of the Federal Food, Drug, and Cosmetic Act. Please choose one of the following:
The hospital will purchase orphan drugs under the 340B Program and maintain auditable records to demonstrate compliance with the orphan drug exclusion.
The hospital cannot or does not wish to maintain auditable records regarding compliance with the orphan drugs exclusion and will purchase all orphan drugs outside of the 340B
Program regardless of the indication for which the drug is used and will not use a Group Purchasing Organization (GPO) to purchase those drugs if the hospital is a free-standing cancer
hospital.
Note: Any change to your selection will be effective on the first day of the quarter following approval by OPA.

Contact Information
Authorizing Official
Name:
Title:
Phone:
Email:

Test User
Chief Executive Officer
999-999-9999 Ext:
[email protected]

Make Primary Contact Information same as Authorizing Official

Primary Contact
Name:
Title:
Phone:
Email:

Test User
Chief Executive Officer
999-999-9999 Ext:
[email protected]

HHS Privacy Policy Notice
U.S. Department of Health and Human Services (HHS)
Health Resources and Services Administration (HRSA)
Office of Pharmacy Affairs (OPA) - 340B Program

OMB Number: 0915-0327, Expiration: 10/31/2015

August 22, 2013
7:19 AM ET

Questions, Comments, or Suggestions
Email Us: [email protected]
Call Us: 1 - 888 - 340 - 2787
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