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Healthcare 340B Requisition Form

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Healthcare 340B Requisition Form

Covered Entity & Request Information

Covered Entity Name Covered Entity Tax ID (EIN) Requesting Contact

Request Date: Request Reference #:

Patient Information

Patient Full Name

Date of Birth: Gender:

Patient Address

Patient Phone: Patient ID at Entity:

Prescriber Information

Prescriber Name

NPI: License #: Office Phone:

Prescriber Office Address

Date of Prescription: Refills Authorized:

Medication Requisition (Complete all applicable fields)

Line 1

Drug Name: Strength: Dosage Form:

Quantity: Days Supply: Directions:

ICD-10 Code: NDC (if available):

Line 2

Drug Name: Strength: Dosage Form:

Quantity: Days Supply: Directions:

ICD-10 Code: NDC (if available):

Line 3

Drug Name: Strength: Dosage Form:

Quantity: Days Supply: Directions:

ICD-10 Code: NDC (if available):

Line 4

Drug Name: Strength: Dosage Form:

Quantity: Days Supply: Directions:

ICD-10 Code: NDC (if available):

Line 5

Drug Name: Strength: Dosage Form:

Quantity: Days Supply: Directions:

ICD-10 Code: NDC (if available):

Insurance / Payment Information

Primary Insurance Provider

Policy Number: Group #: Subscriber Name:

340B Eligibility Certification

By checking the box below and signing this form, the patient (or authorized representative) certifies that the patient is a valid patient of the covered entity named above and meets the covered entity's definition of a 340B-eligible patient. The patient acknowledges that medications obtained under the 340B program will be used by the patient for the condition for which they were prescribed and that the medication will not be resold or redistributed for commercial use. Patient further certifies that the same item has not been billed for duplicate discounts under any other federal drug discount program.

I certify under penalty of law that the statements above are true and accurate and that I meet the covered entity's eligibility criteria.

HIPAA Authorization & Release

I authorize the covered entity and the dispensing pharmacy to use and disclose protected health information as necessary to process this requisition and to coordinate benefits, verify eligibility, and to facilitate provision of medication. I understand that information disclosed pursuant to this authorization may include diagnosis, medication, and insurance information. I understand that I may revoke this authorization in writing at any time, except to the extent the covered entity has already relied on the authorization.

I acknowledge receipt of the privacy practices and authorize release of information as described above.

Authorization Period

This authorization is effective immediately and will expire on: unless earlier revoked in writing.

Pharmacy Use (To be completed by dispensing pharmacy)

Pharmacy Name

Pharmacy NPI: Contract Pharmacy ID: Date Dispensed:

Pharmacist Initials: Fill Quantity Verified:

Additional Instructions

Representative / Guardian (if applicable)

If signing on behalf of the patient, print name of representative:

Relationship to Patient

Patient Name:

By:

Date:

What the Healthcare 340B Requisition Form Is

The Healthcare 340B Requisition Form is a standardized document used by covered entities and associated pharmacies to request medications or discounts under the federal 340B Drug Pricing Program. It captures patient identifiers, clinic and pharmacy details, prescriber and drug data, and program enrollment information so purchases can be linked to an eligible 340B encounter and tracked for audit and compliance.

Why this form matters for program compliance and inventory control

A complete, accurate requisition ensures purchases are processed at 340B pricing, supports audit readiness, and documents the clinical linkage required by program rules. Proper form handling reduces diversion risk and helps covered entities maintain program eligibility.

Why this form matters for program compliance and inventory control

Who typically completes the Healthcare 340B Requisition Form

The form is completed by staff who manage 340B ordering, pharmacy contracts, or encounter documentation.

Covered entity pharmacy manager responsible for enrolling claims and maintaining inventory controls.
Contract pharmacy administrator who submits orders and reconciles 340B dispensing records.
340B compliance officer or auditor who prepares documentation for HRSA or internal review.

Teams should assign clear ownership for creation, approval, and retention of each requisition to reduce audit findings and maintain traceability.

Essential data elements the form must include

Patient Name: Full legal name

Date of Birth: MM/DD/YYYY

Facility Identifier: HRSA/Entity ID

Prescriber NPI: 10-digit NPI

Medication Details: Drug, strength, quantity

Signature / Authorization: Signed by authorized agent

Key components of a professional Healthcare 340B Requisition Form

A well-structured requisition groups contact and payer data, identifiers for program linkage, precise medication details, authorization signatures, audit metadata, and a section for attachments or supporting documentation.

Header

Facility and pharmacy contact details, program enrollment identifiers, and requisition reference number to support traceability and record matching.

Patient and Encounter

Patient name, DOB, MRN, encounter date and location to document clinical linkage required by program rules.

Prescriber Details

Prescriber name, NPI, DEA if needed, and contact for verification and retrospective audits.

Drug Order

Drug name, strength, NDC, quantity, and dispensing instructions to avoid fulfillment errors and reconcile inventory.

Authorization

Signature block with printed name, title, and date; include electronic signature metadata if signed digitally.

Audit Metadata

Fields for order origin, approver, system logs, and attachments such as encounter notes or prescriptions.

Step-by-step: completing a Healthcare 340B Requisition Form

Follow a clear sequence to collect identifiers, record clinical linkage, obtain authorization, and submit the request to the pharmacy or vendor.

01

Gather Identifiers: Collect patient name, DOB, MRN, facility ID, and prescriber NPI.
02

Enter Medication Data: Record drug name, strength, NDC, quantity, and intended dispensing location.
03

Obtain Authorization: Get required signatures and designate the authorized signer with title and date.
04

Submit and Log: Send to pharmacy vendor, record submission timestamp, and retain stored copy for audits.

Configuring an online requisition workflow

Set up fields, validation rules, and recipient routing to reduce manual steps and ensure consistent data capture.

Field	Configuration
Patient ID Validation	Require numeric MRN, unique per patient
NPI Field	Validate length to 10 digits
Required Attachments	Enforce upload of encounter note or prescription
Approval Routing	Route to compliance officer then pharmacy

Digital signing and integration considerations

Use a platform that supports secure eSignatures, common file formats, and integrations with EHR or pharmacy systems to streamline processing.

File Formats: PDF | DOCX | HTML | Excel
Integrations: EHR, ERP, NetSuite, Salesforce
Security: AES-256 at rest, TLS 1.2/1.3

Where to send the completed Healthcare 340B Requisition Form

Route the signed requisition to the pharmacy partner, retain a copy in the covered entity record system, and record the transaction for reconciliation and audit.

Internal Record: Store signed copy in the EHR or document management system
Contract Pharmacy: Send requisition to the contract pharmacy for fulfillment and reconciliation
Wholesaler / Vendor: Provide necessary order info to the wholesaler for 340B-priced purchase
Compliance Archive: Retain metadata and attachments for audit readiness

Timelines and processing expectations for requisitions

Processing times and audit windows vary by organization and vendor; plan for same-day to multi-day fulfillment and maintain records to meet audit requests.

Fulfillment Time:

Same-day to 72 hours depending on stock and vendor

Audit Availability:

Provide records within a reasonable period, often 10 business days

Annual Attestation:

Covered entities often complete yearly program attestation per HRSA guidance

Reconciliation Cycle:

Monthly or quarterly reconciliation recommended for inventory and billing

Exception Handling:

Document and escalate discrepancies within 5 business days

Key processing milestones for a requisition

Track a requisition through creation, approval, fulfillment, and archival so every stage is auditable and exceptions are managed quickly.

01

Request Created

Form completed and saved with timestamp

02

Compliance Approval

Program reviewer confirms eligibility and signs

03

Pharmacy Fulfillment

Order sent to vendor and dispensed

04

Archive and Reconcile

Records stored and matched against invoices

Common mistakes when preparing the Healthcare 340B Requisition Form

Using inconsistent patient identifiers across systems, which prevents correct encounter matching and causes audit exceptions.
Entering an incorrect NPI or facility ID, breaking the link between prescription and eligible 340B encounter.
Failing to attach the supporting encounter note or prescription, which impairs auditability and may lead to disallowed claims.
Not recording authorization metadata (who approved and when), making it difficult to demonstrate internal controls.

Penalties and operational risks of incorrect or missing requisitions

Loss of Discounts: Disallowed purchases

Audit Findings: Program noncompliance citations

Repayment Liability: Potential reimbursements required

Contract Termination: Vendor or pharmacy risk

Regulatory Scrutiny: Increased HRSA oversight

Patient Impact: Interrupted access to therapy

How to download, save, and attach supporting documents

Export signed requisitions in standard formats and include encounter notes or prescriptions as supporting attachments for audit trails.

Download Formats

Save final records as PDF/A for long-term archiving; also export DOCX or Excel for internal reconciliation and reporting workflows.

Embedded Audit Trail

Include signature metadata (timestamps, IP addresses, authentication method) inside the document package to support legal admissibility.

Supporting Attachments

Attach encounter notes, prescriptions, and invoices as separate files or appended PDFs to demonstrate clinical linkage during audits.

Version Control

Keep a single signed version marked final and retain earlier drafts only if necessary for dispute resolution.

eSignature solutions: pricing and capability snapshot for form processing

Compare entry-level pricing, trial availability, bulk send capability, audit trails, and HIPAA compliance to evaluate providers for 340B requisition workflows.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about the Healthcare 340B Requisition Form

Answers to common operational and compliance questions when preparing, signing, and storing 340B requisitions.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.
Is a notary required for the requisition?
Not typically required for 340B requisitions, but state or vendor policies may request notarization for certain authorizations; verify local rules before requiring notarization.
Who may sign on behalf of the covered entity?
An authorized official or designee with delegated signature authority should sign; document the delegation in internal policies to support audit questions.
How long must we retain completed requisitions?
Retain per federal and program requirements: at minimum follow HIPAA 6-year rule and IRS/financial retention norms; many entities retain for 7 years for audit defense.
What happens if identifiers do not match?
Mismatched patient or prescriber identifiers can break the clinical linkage, result in disallowed purchases, and trigger audit recovery or corrective action.
How to correct an already-submitted requisition?
Issue a corrected requisition with clear references to the original, log the correction, and notify affected vendors and reconciliation teams to update records.

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