340B Health

Health System Application Form

Thank you for your interest in joining 340B Health!

This form is for hospitals that are joining as part of a health system. If your hospital is part of a system in which other 340B hospitals already have a 340B Health membership, you do not need to complete this form. Please contact Shane Kelley at shane.kelley@340bhealth.org or 202-552-5864 to have your hospital added to the health system membership and to have the group discount applied to your account.

Please note, in accordance with our bylaws all hospitals within a health system that are enrolled in the 340B program must be included in your membership. Significant group discounts are available for health systems. Please submit the form below with your health system's information.

If your hospital wishes to join 340B Health and is not part of a health system where there are other 340B hospitals, please use our Hospital Application Form.

Once your application is processed, an invoice will be sent to you. Membership benefits will begin upon receipt of dues payment.

*Required fields are indicated with an asterisks (*). If you do not have information for a required field, please enter N/A.

Hospital System Information

Health System Contacts

Please enter the contact information for the following health system contacts. Additional contacts can be added later in the application process.

*Health System's Principal Contact Person (Primary Billing Contact)

The Primary Billing Contact is the individual designated by a health system to handle matters related to billing (only one per health system).

Health System's Chief Financial Officer

Health System's Chief Executive Contact (e.g. CEO, COO, President)

Health System's Government Advocacy Key Contact