REDLINE Manufacturer Change Form

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

OMB No. 0915-0327

340B MANUFACTURER CHANGE FORM

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

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 .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 14N-39, Rockville, Maryland, 20857.