2 Contract Pharmacy Termination

340B Contract Pharmacy Termination
Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau
OMB No. 0915-0327; Expiration Date: XX/XX/20XX

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Please review the list of active contract pharmacy arrangements for this entity. If you want to request a contract termination, select the appropriate contract(s), requested termination date(s) and
termination reason(s).
Note: The covered entity’s authorizing official will be notified by email and will have 15 calendar days to approve or reject the proposed contract pharmacy termination(s).
Termination Date: The covered entity is responsible for reporting an accurate termination date for each contract pharmacy arrangement. It is expected that 340B activity has ceased or will cease on
the termination date requested.

Active Contracts
Request
to
Pharmacy Name
Terminate

City

State Start Date

Requested Termination Date

Termination Reason








































































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 0.5 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-03I, Rockville, Maryland,
20857.

Active Contract Selected for Termination for %,'&RYHUHG(QWLW\7\SH

Note: The covered entity’s authorizing official will be notified by email and will have 15 calendar days to approve or reject the proposed contract pharmacy termination(s).
Note: An asterisk (*) next to a field name denotes a required field.

Pharmacy Name

City

State

Start Date

Requested Termination Date

Termination Reason

Requestor Details

*Name:
*Title:
*Organization:
* Phone:
(xxx-xxx-xxxx)

Ext:

*Email:
Remarks:

Submit and Continue

March 06, 2015

10:08 AM ET

Cancel

[email protected] | 1-888-340-2787

OMB Number: 0915-0327, Expiration: ;;;;;;

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Active Contract Selected for Termination for %,'&RYHUHG(QWLW\7\SH

Contract Termination Request Confirmation
The covered entity’s authorizing official will be notified by email and will have 15 calendar days to approve or reject the proposed contract pharmacy termination(s).

Pharmacy Name

City

State

Start Date

Requested Termination Date

Termination Reason

Continue

March 06, 2015

10:09 AM ET

[email protected] | 1-888-340-2787

OMB Number: 0915-0327, Expiration: ;;;;;;

Ask Questions | Viewers & Players | Privacy Policy | Disclaimers | Accessibility | Freedom of Information Act | No Fear Act | USA.gov | WhiteHouse.gov | Recovery.gov

This request has been processed.

For additional assistance, please contact the 340B Prime Vendor Program at 1-888-347-2787 or by email at [email protected].
You may also contact OPA at:
Office of Pharmacy Affairs
Mail Stop 8W03A
5600 Fishers Lane
Rockville, MD 20857

Done

March 06, 2015

10:57 AM ET

[email protected] | 1-888-340-2787

OMB Number: 0915-0327, Expiration: XX/XX/20XX

Ask Questions | Viewers & Players | Privacy Policy | Disclaimers | Accessibility | Freedom of Information Act | No Fear Act | USA.gov | WhiteHouse.gov | Recovery.gov