Form 1 Conmmunity Health Center Recert

Consolidated Health Center Recertification

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

Covered Entity Details
340B ID:
Entity Type:

Entity Name:
Entity Sub-Division Name:

Employer Identification Number:

Medicare Provider Number:

Grant Number:
Site ID:

Covered Entity Address
Street Address (PO Box Not Allowed)

Continue

Undo

*Address Line 1:
Address Line 2:
*City:

L

*State:
*Zip:

-

Billing Address Same as Street Address





Billing Address

Continue

Undo

*Organization Name:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip:

-

Shipping Address Same as Street Address






Alternative Methods





Shipping Address (PO Box Not Allowed)

Add

New Shipping Address

Continue

*Organization Name:
*Address Line 1:
Address Line 2:
*City:
*State:

Select a State

*Zip:

-

Covered Entity Date Information
Registration Date:

Participating Start Date:

Participating Approval Date:

Termination Reason:

Undo

Termination Date:
The date the entity became ineligible:
Last date that 340B drugs were or will be
purchased under this 340B ID:
Termination Comments:

Medicaid Billing
Medicaid Billing Information
You must answer the following question regarding Medicaid Billing:
Will you bill Medicaid for drugs purchased at 340B drug price?

 Yes









 No
Yes 

Contact Information
Authorizing Official
Name:
Title:
Phone:
Email:

Ext:

Make





Make Primary Contact Information same as
as Authorizing
Authorizing Official
Primary Contact
Name:
Title:
Phone:
Email:

Ext:

Update

March 06, 2015

11:20 AM ET

Terminate

[email protected] | 1-888-340-2787

Cancel

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

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Consolidated Health Center Program Grantee/ Program
Manager Batch Certification 2015

NOTE: Recertification is not complete until you check the certification statement below and
click the "Attest and Recertify" button.
Covered Entities
Rows/Page:

340B ID

Batch
Name

Subdivision
Name

Entity Name

Address

200

Set
City

State Zip

Status

Program Manager/Authorizing Official
Name:
Title:
Phone:
Email:

Ext:

Authorized Signature







The undersigned represents and confirms 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. Failure to recertify may be grounds for removal from the 340B Program.
The undersigned further acknowledges the 340B covered entity’s responsibility to abide by the following:
As an Authorized Official, I certify on behalf of the covered entity that:
(1) all information listed on the 340B Program database for the covered entity is complete, accurate, and correct;
(2) the covered entity meets all 340B Program eligibility requirements, including section 340B(a)(4)(L)(iii) of the Public Health Service Act when applicable, regarding the group
purchasing organization prohibition - which states that the covered entity hospital does not obtain covered outpatient drugs through a group purchasing organization or other group
purchasing arrangement;
(3) the covered entity will comply with all requirements of Section 340B of the Public Health Service Act and any accompanying regulations including, but not limited to, the prohibition
against duplicate discounts/rebates and diversion (section 340B(a)(5)(A) and (B) of the Public Health Service Act);
(4) the covered entity maintains auditable records pertaining to compliance with the requirements described in paragraph (3) above, pursuant to section 340B(a)(5)(C) of the Public
Health Service Act;
(5) if the covered entity uses contract pharmacy services, that the contract pharmacy arrangement will be performed in accordance with OPA requirements and guidelines;
(6) the covered entity acknowledges its responsibility to contact OPA as soon as possible if there is any change in 340B eligibility and/or breach by the covered entity of any of the
foregoing; and
(7) the covered entity acknowledges that if there is a breach of the requirements described in paragraph (3) that the covered entity may be liable to the manufacturer of the covered
outpatient drug that is the subject of the violation, and, depending upon the circumstances, may be subject to removal from the list of eligible 340B entities.

Please provide any additional information that may be helpful in reviewing this recertification request, and/or any requested changes to the entity's 340B record:

Attest and Recertify

March 06, 2015

11:26 AM ET

[email protected] | 1-888-340-2787

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

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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 .05 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.