340B Pre-Enrollment Eligibility Assessment

1

Your Organization

Basic information so we know who we're talking to.

Organization name

Your name

State

City

Which best describes your organization?

Ryan White Part A (TGA/EMA)
Very likely eligible

FQHC / FQHC Look-Alike
Very likely eligible

STD Clinic (PHS Section 318)
Likely eligible

TB Clinic (PHS Section 317)
Likely eligible

Title X Family Planning
Likely eligible

Disproportionate Share Hospital (DSH)
Depends

Critical Access Hospital (CAH)
Depends

Other / not sure
Assessment needed

2

Federal Funding

340B eligibility is grounded in your federal grant status.

Do you currently receive federal grant funding?

Yes — currently receiving

Yes — but funding is ending soon

Applying / in process

No federal funding

Which federal agency funds you?

Do you have your federal grant number?

Yes, I have it

I can find it

Not sure

Are you a direct grantee or subgrantee?

Direct HRSA/CDC grantee

Subgrantee / subrecipient

Direct grantee AND subgrantee

N/A

3

Patients, Services & Pharmacy

Volume and dispensing model shape your revenue potential.

Total active patients (approx.)

Patients receiving prescriptions (approx.)

How are prescriptions dispensed today?

In-house pharmacy

Contract pharmacy

Both

No pharmacy dispensing yet

What types of medications do you prescribe? (select all that apply)

Antiretrovirals (ARVs)

PrEP / PEP

Primary care medications

Specialty medications

STD/STI treatment

Mental health / behavioral health

What's your general payer mix?

Mostly commercial insurance

Mostly Medicaid

Mostly uninsured / self-pay

Mixed payer base

4

Organizational Readiness

HRSA registration checks a few operational boxes before approval.

Do you have an active governing board?

Yes, active governing board

Yes, but not very active

No / not applicable

SAM.gov registration status

Yes, current

Expired / needs renewal

No

Not sure

What EHR / records system do you use?

Do you have pharmacist support?

Yes, on staff

Yes, via contract pharmacy

No / not yet

Nonprofit / governmental status

Yes, 501(c)(3)

Government entity

Forming / new

No

5

Goals, Timeline & Revenue Potential

Helps us tailor your eligibility report and next steps.

What's your primary goal with 340B?

Generate 340B program revenue

Reduce drug acquisition costs

Both

Just exploring

What's your enrollment timeline?

Next HRSA registration window

This calendar year

Next year

No specific timeline yet

What's your biggest concern about 340B?

Whether we qualify

Program complexity / compliance

Finding a contract pharmacy

Staff bandwidth

Whether it's worth it

Where to start

Anything else we should know? (optional)