Contract Pharmacy Registration Form

Enrollment and Re-Certification of Entities in the 340B Drug Pricing Program and Collection of Manufacturer Data to Verify 340B Drug Pricing Program Ceiling Price Calculations

OMB: 0915-0327

IC ID: 190354

Information Collection (IC) Details

View Information Collection (IC)

Contract Pharmacy Registration Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 1 Contract Pharmacy Registration-Revised Contract Pharmacy Registration-Revised.pdf Yes Yes Fillable Fileable
Form 2 Contract Pharmacy Termination Contract Pharmacy Termination.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

1,758 1,200
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 8,790 0 0 0 0 8,790
Annual IC Time Burden (Hours) 8,790 0 0 0 0 8,790
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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