Form 1 340B Manufacturer Change Form-Revised

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

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

340B MANUFACTURER CHANGE FORM

The original signatory to the Pharmaceutical Pricing Agreement, current designated contact person, or a current corporate officer should e-mail the completed form to the Office of Pharmacy Affairs at [email protected]; submission by anyone else may result in significant delays. Requestors will be notified when the changes have been made.

Section 1. Required Information. Complete this section as it appears on the 340B database.

Section 2. Updated Information. Only complete information that is to be changed.

Manufacturer Name:
Sub-Division Name:
New Physical Address:
New Physical Address City:
New Physical Address State, Zip:
CMS Termination Date:

New Authorizing Official:
New Authorizing Official Title:
New Authorizing Official Phone #:		Ext:
New Authorizing Official E-mail Address:

New Contact Person:
New Contact Title:
New Contact Phone #:		Ext:
New Contact E-mail Address:

Note: The original signatory to the Pharmaceutical Pricing Agreement cannot be changed.

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.

SUBMIT FORM TO :::::::::::::::::::::::> [email protected]

Update of this information is subject to approval and verification by the Office of Pharmacy Affairs.