Get Std Or Tb Programs - Hrsa - Ftp Hrsa

Completing the STD Or TB Programs - HRSA - Ftp Hrsa form is an essential step for entities seeking to participate in the 340B program. This guide provides clear instructions to ensure accurate and efficient completion of the form, enabling organizations to benefit from reduced pharmaceutical pricing.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling in the 'Covered Entity Name' and the street address. Ensure that all parts of the address are accurate, including city, state, and ZIP code.
3. If applicable, provide a different billing address by filling out the appropriate section. If the shipping address for pharmaceuticals varies from the covered entity address, complete that section as well.
4. Identify the entity type by circling either 'STD' or 'TB' as appropriate for your organization.
5. If you know your Grant ID, enter it in the designated line to assist with processing your registration.
6. Answer the Medicaid billing question by indicating whether you intend to bill Medicaid for drugs purchased at 340B prices. If 'Yes,' include your Pharmacy Medicaid Provider Number.
7. In the signed agreement section, ensure that the 'Grantee Representative Name,' 'Title,' 'Signature,' and 'Date' fields are accurately filled. The representative must be appropriately authorized to bind your organization.
8. Complete the 'Grantee Representative Telephone' and 'Email' fields to provide complete contact information.
9. Fill out the entity contact information for the individual who will be the primary contact regarding the 340B program.
10. Review the form thoroughly to ensure all fields are completed accurately before finalizing your submission.
11. Once the form is complete, submit the original signed form to the Office of Pharmacy Affairs at the specified address and consider faxing it if close to a deadline.

Begin the process now by completing the STD Or TB Programs - HRSA - Ftp Hrsa form online.