2 Cert state or local government-Revised

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.

Name of Hospital

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Official certifies that immediate notice will be provided to the Office of Pharmacy Affairs when this contract is no longer valid.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.

Hospital Authorizing Official Signature Date

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

Phone Number Ext. E-Mail Address

State or Local Government Official Signature Date

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

Title and Unit of Government

Address

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).