Forms

Submit Change Requests On-Line | Terminations, Authorizing Official, Contract Pharmacy & Manufacturer Requests Still Use PDF Change Forms | Entities must register online but that certain forms must be downloaded, signed and submitted to OPA. Users should review the eligibility page for their entity type for more details.

Federal Register Notices | Policy Releases | Manufacturer Notices | Reports | Section 340B of the Public Health Service Act

Forms

340B Participant Change Form (PDF - 107 KB)

340B Manufacturer Change Form (PDF - 29.8 KB)

Pharmaceutical Pricing Agreement for Manufacturers (PDF - 43.7 KB) Send two signed originals so one can be returned to you.

Certification of Contract between Private, Non-profit Hospital, and State/Local Government (PDF - 14.6 KB)

Hospital Certification for Ownership/Operation (PDF - 17 KB)

For Reference Only

Group Purchasing Organization Certification (PDF - 238 KB)

340B Registration for Covered Entities (PDF - 487 KB)

340B Registration for Disproportionate Share Hospitals (PDF - 471 KB)

340B Registration for Rural Referral Centers and Sole Community Hospitals (PDF - 471 KB)

340B Registration for Outpatient Facilities (PDF - 463 KB)

340B Registration for Critical Access Hospitals (PDF - 465 KB)

340B Registration for Children's and Free Standing Cancer Hospitals (PDF - 468 KB)

Program Integrity

340B Drug Pricing Program covered entities must ensure program integrity and maintain accurate records documenting compliance with all 340B Program requirements.

Covered entities are subject to audit by manufacturers or the federal government. Failure to comply may make the 340B covered entity liable to manufacturers for refunds of discounts obtained.

Learn more: Program Integrity