CONTRACT RE CERTIFICATION WITH OPA DHHS HRSA.PDF

Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau
OMB No. 0915-0327; Expiration Date: 10/31/2015
OFFICE OF PHARMACY AFFAIRS (OPA)
CERTIFICATION OF CONTRACT BETWEEN PRIVATE, NON-PROFIT HOSPITAL AND
STATE/LOCAL GOVERNMENT TO PROVIDE HEALTH CARE SERVICES TO LOW INCOME
INDIVIDUALS
To demonstrate that the hospital meets the statutory definition of covered entity under section
340B(a)(4)(L)(i) as a private non-profit hospital which has a contract with a State or local
government to provide health care services to low income individuals, this certification must be
completed and signed by both parties.
Phoenix Children’s Hospital, Inc.
Name of Hospital
Phoenix, Arizona, 85016
City, State, Zip
Pursuant to the requirement of Section 340B of the Public Health Service Act
(42 U.S.C. 256b), I certify that a valid contract ( C-86-13-057-3-00) is currently in
place between the private, non- profit hospital named above, and the State or
Local Government Entity named below, to provide health care services to low
income individuals who are not entitled to benefits under Title XVIII of the Social
Security Act or eligible for assistance under the State plan of Title XIX of the
Social Security Act. In addition, the authorizing official certifies that when this
contract is no longer valid, appropriate notice will be provided to the Office of
Pharmacy Affairs. The undersigned represents and confirms that he/she is fully
authorized to legally bind the covered entity and certifies that the contents of any
statement made or reflected in this document are truthful and accurate.
Signature of Hospital Authorizing Official Date
Robert L. Meyer, President and Chief Executive Officer
Name and Title of Authorizing Official (e.g., CEO, CFO, COO) (please print or type)
(602) 933-0400 RMeyer@phoenixchildrens.com
Phone Number Ext. E-Mail Address
Signature of State or Local Government Official Date
Steve Chucri
Name of State or Local Government Official (please print or type)
Chairman, Maricopa County Board of Supervisors
Title and Unit of Government
4041 N. Central Ave. Phoenix, Arizona, 85012
Address
(602) 506-6901 BobEngland@mail.maricopa.gov
Phone Number Ext. E-Mail Address
This registration form must be completed and submitted according to the established deadlines that are published on the OPA website (www.hrsa.gov/opa).

C-86- ATTACHED TO AND A PART OF
Office of Pharmacy Affairs (OPA)
Certification of Contract between Private, Non-
profit Hospital and State/Local Government to
Provide Health Care Services to Low Income
Indivividuals
IN WITNESS WHEREOF, the parties agree to enter into this Contract:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Attorney for Maricopa County
Date