| Section 1: Covered Entity Identifiable Information |
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| Field Name |
Response Format |
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| Covered Entity Name* |
Text |
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| Covered Entity 340B ID* |
Text and Numbers |
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| *As reported in the OPA OPAIS database. See: https://340bopais.hrsa.gov/home |
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| Section 2: Covered Entity Reported Data Elements Form** |
| Claim Date of Service |
Prescription Number |
Fill Number |
Dispensing Pharmacy NPI |
NDC-11 |
Claim Record Indicator |
| YYYY-MM-DD |
999999999999999999999999999999 |
999999999 |
9999999999 |
99999999999 |
(A): Add, (R): Remove |
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| **Additional rows should be added when submitting additional claims |
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