Get Online Contract Pharmacy Registration Form For The 340b Program - Ftp Hrsa

Filling out the Online Contract Pharmacy Registration Form for The 340B Program is a critical step for ensuring compliance with healthcare regulations. This guide provides detailed, step-by-step instructions on how to accurately complete the form and submit it online.

Follow the steps to successfully complete the registration form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editable format.
2. Begin by entering the 340B ID number in the designated field. This number is essential for identifying your Covered Entity in the 340B Program.
3. Fill in the 'Covered Entity Name' field with the full legal name of your organization that is applying for 340B Program participation.
4. Provide the 'Street Address', 'City', 'State', and 'Zip' code for the Covered Entity. Ensure that this information is accurate and up to date.
5. Next, complete the section for the 'Pharmacy Name'. This should reflect the name of the entity that will be providing pharmacy services.
6. Enter the corresponding 'Street Address', 'City', 'State', and 'Zip' code for the Pharmacy in the provided fields.
7. The undersigned must sign the document in the designated 'Signature of Authorizing Official of Covered Entity' area, along with the date in the specified format.
8. Complete the 'Type or Print Name and Title' fields, ensuring the name listed is the authorizing official along with their title.
9. The Pharmacy's Responsible Representative must also provide their signature in the appropriate section along with the date.
10. Lastly, type or print the name and title of the Responsible Representative of the Pharmacy as required.
11. Once all sections are completed, review the entire form for accuracy. You can then save your changes, download the document, print it, or share it as needed.

Complete your registration forms online today to ensure compliance and continue providing vital pharmacy services.