2 Cert state or local government-Revised

340B Drug Pricing Program Forms

Cert state or local government-Revised

340B Program Registrations amp; Certifications for Children's 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)

CERTIFICATION OF CONTRACT BETWEEN PRIVATE, NON-PROFIT HOSPITAL AND STATE/LOCAL GOVERNMENT TO PROVIDE HEALTH CARE SERVICES TO LOW INCOME INDIVIDUALS


This certification must be completed and signed by representatives from the parties specified below acknowledging the hospital meets the eligibility requirement in section 340B(a)(4)(L)(i) of the Public Health Service Act regarding a private non-profit hospital which has a contract with a State or local government to provide health care services to low income individuals.

Shape1



Shape2

Name of Hospital



Shape3

Street Address, City, State, Zip


Pursuant to section 340B(a)(4)(L)(i) of the Public Health Service Act, the Hospital Authorizing Official certifies that a valid contract (please provide contract number or identifier below if applicable) is currently in place between the private, non-profit hospital named above, and the State or Local Government Entity named below, to provide health care services to low income individuals who are not entitled to benefits under Title XVIII of the Social Security Act or eligible for assistance under the State plan of Title XIX of the Social Security Act. The Hospital Authorizing Official certifies that immediate notice will be provided to the Office of Pharmacy Affairs when this contract is no longer valid. The Hospital Authorizing Official 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.



Shape4 Shape5

Hospital Authorizing Official Signature Date


Shape6

Name and Title of Authorizing Official (e.g., CEO, CFO, COO)


Shape7 Shape8 Shape9

Phone Number Ext. E-Mail Address



Shape10 Shape11

State or Local Government Official Signature Date


Shape12

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


Shape13

Title and Unit of Government


Shape14

Address


Shape15 Shape16 Shape17

Phone Number Ext. E-Mail Address



Contract Number or Identifier, if applicable: __________________


Contract start date: __ / __ / ____ Contract end date: __ / __ / ____


    • Check here if the entity’s contract is valid until cancelled.


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



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDepartment of Health and Human Services Health Resources and Services Administration HealthCare Systems Bureau
AuthorHRSA
File Modified0000-00-00
File Created2021-01-25

© 2024 OMB.report | Privacy Policy