Get the free 340B Participant Change Form - hrsa

Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau OMB No. 0915-0327; Expiration Date: 10/31/2015 340B PARTICIPANT CHANGE From This form

How to fill out 340b participant change form

Who needs 340b participant change form?

1. Covered entities participating in the federal 340B Drug Pricing Program.
2. These covered entities may include various types of healthcare providers, such as hospitals, clinics, and health centers, that meet specific eligibility criteria.

How to fill out 340b participant change form:

1. Obtain the form: Start by downloading or requesting the 340b participant change form from the appropriate authority or organization responsible for administering the 340B program. This could be the Health Resources and Services Administration (HRSA) or a designated 340B program administrator.
2. Gather necessary information: Before filling out the form, gather all the required information. This may include the covered entity's unique identifier, such as the 340B ID, DSH ID, and Medicaid ID. Additionally, you may need to provide details about the changes you wish to make, such as adding or removing contract pharmacies, changing authorizing officials, or updating contact information.
3. Complete the form: Fill out the form accurately and legibly, ensuring all required fields are completed. Double-check the information for accuracy before submitting the form. Provide any supporting documentation that may be requested, such as pharmacy licenses, agreements, or other relevant paperwork.
4. Review and authorize: Once you have completed the form, review it thoroughly to ensure all information is correct. If there are any mistakes or missing details, make the necessary corrections before submitting the form. Authorized individuals within the covered entity, such as CEOs or CFOs, may need to sign and authorize the form.
5. Submit the form: Follow the instructions provided by the 340B program administrator or authority to submit the form. This may involve submitting it electronically through an online portal, mailing it to the designated address, or emailing it to the appropriate contact.
6. Keep a copy: Make a copy of the filled-out and submitted form for your records. It is important to retain a copy in case of any future inquiries or audit requests.

Remember, the process and requirements for filling out the 340B participant change form may vary depending on the specific program administrator or authority overseeing the 340B program. It is advisable to consult the program guidelines or seek assistance from the appropriate authority if you have any questions or need further clarification.

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What is 340b participant change form?

340b participant change form is a form used to update information about covered entities participating in the 340B Drug Pricing Program.

Who is required to file 340b participant change form?

Covered entities participating in the 340B Drug Pricing Program are required to file the 340B participant change form.

How to fill out 340b participant change form?

To fill out the 340B participant change form, covered entities must provide updated information such as changes in contact information, eligibility status, or site additions/removals.

What is the purpose of 340b participant change form?

The purpose of the 340B participant change form is to ensure accurate and up-to-date information on covered entities participating in the 340B Drug Pricing Program.

What information must be reported on 340b participant change form?

Information such as covered entity name, address, contact information, 340B ID, eligibility status, and site additions/removals must be reported on the 340B participant change form.