covered entity application

1 Forward this form to your 340B Authorizing Official (AO) or Primary Contact (PC)

2 The Covered Entity AO or PC will complete this application.

3 The AO or PC will designate in your organization to someone add the pharmacies in the portal for the clinic. This person can be a 340B Program Manager, a 340B Consultant, Account Manager, the AO or PC or any representative of the covered entity. If you rather have us manage your pharmacies, let us know!

4 There is no cost for this service!

Note: If your covered entity is not listed, please contact us.

The 340B Drug Pricing Program is managed by the Health Resources and Services Administration (HRSA) Office of Pharmacy Affairs (OPA). For more information visit: This material is provided for general informational purposes of 340B Drug Prices only and is not an endorsement of any prescription product referenced herein. For information as to the clinical use or efficacy of a referenced product, please contact the manufacturer. 340B Price Guide makes no representations and provides no warranties as to the effectiveness or suitability for use of any prescription product referenced herein. Any referenced cost is provided as an estimate only and the actual cost is subject to change at any time and without notice. 340B Price Guide does not guarantee that the cost represented herein will be the actual and pharmacy shall at all times collect amounts due as indicated at the time of adjudication and shall be reimbursed per the terms of its agreement.'