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H H S Department of Health and Human Services
Health Resources and Services Administration
Health Resources and Services Administration

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Forms

Submit Change Requests On-Line | Terminations, authorizing official (where the existing official is no longer available), contract pharmacy and manufacturer requests still use PDF Change forms  | Entities must register online, but certain forms must be downloaded, signed and submitted to OPA. For details on requirements for each entity type, please review the eligibility page.

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

Forms

340B Participant Change Form (PDF - 121 KB)

340B Manufacturer Change Form (PDF - 29 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 - 76 KB)

340B Registration for Disproportionate Share Hospitals (PDF - 263 KB)

340B Registration for Rural Referral Centers and Sole Community Hospitals (PDF - 265 KB)

340B Registration for Outpatient Facilities (PDF - 363 KB)

340B Registration for Critical Access Hospitals (PDF - 264 KB)

340B Registration for Children’s Hospitals (PDF - 265 KB)

340B Registration for Free Standing Cancer Hospitals (PDF - 266 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

Questions, contact ApexusAnswers@340BPVP.com or call 1-888-340-2787 Monday through Friday 8:30am to 6:30pm