3 Public Ownership-Revised

340B Drug Pricing Program Forms

Public Ownership-Revised

340B Program Registrations amp; Certifications for Disproportionate Share Hospitals

OMB: 0915-0327

Document [docx]
Download: docx | pdf

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

OMB No. 0915-0327; Expiration Date: XX/XX/20XX


OFFICE OF PHARMACY AFFAIRS (OPA) HOSPITAL CERTIFICATION OF OWNERSHIP/OPERATION

BY A UNIT OF STATE/LOCAL GOVERNMENT


This certification must be completed and signed by representatives from the parties specified below acknowledging the eligibility requirement in section 340B(a)(4)(L)(i) of the Public Health Service Act regarding ownership/operation by a unit of state/local government.


Shape1



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.)


Shape5 Shape4 Shape6 Owned Operated Both



Shape7

State or Local Government Official Signature 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 certifies 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. The undersigned certifies that the ownership and/or operating status identified above is currently valid, and agrees to inform the Office of Pharmacy Affairs of any change as soon as possible.



Hospital Authorizing Official Signature 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 0915-0327. Public reporting burden for this collection of information is estimated to average 2.0 hours per response, including the time for reviewing instructions, searching existing data sources, 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 10C-26, Rockville, Maryland, 20857.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKButcher
File Modified0000-00-00
File Created2021-01-25

© 2024 OMB.report | Privacy Policy