2 GPO FOrm

D epartment 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)

This certification must be signed to demonstrate that the hospital meets the statutory requirement under section 340B(a)(4)(L)(iii), which is reiterated in the Statutory Prohibition on Group Purchasing Organization Participation Policy Release 2013-1 that requires that the hospital does not obtain covered outpatient drugs through a group purchasing organization or other group purchasing arrangement. 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

_______________________ Ext._____________ 

Phone Number

____________________________________________________________________

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.