Form F-62643 - Drug Repository Program Form - Notice Of Participation Or Withdrawal
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
F-62643 (Rev. 07/10)
DRUG REPOSITORY PROGRAM
NOTICE OF PARTICIPATION OR WITHDRAWAL
●
Completion of this form meets the notification requirement for participation in, or withdrawal from, the Drug Repository Program
under Chapter DHS 148.04(2) and (3), Wis. Admin. Code.
●
Complete and submit this form to the following address:
Drug Repository Program
Division of Quality Assurance
PO Box 2969
Madison, WI 53701-2969
or FAX to 608-267-7119
●
Questions about completing this form may be directed to 608-266-5388.
NOTICE OF PARTICIPATION - PHARMACY OR MEDICAL FACILTY
A pharmacy or medical facility may fully participate in the drug repository program by accepting, storing and dispensing donated
drugs and supplies or may limit its participation to only accepting and storing donated drugs and medical supplies. Check one of
the following:
Full Participation (Will dispense drugs and supplies)
Partial Participation (Will not dispense drugs and supplies)
Name – Pharmacy or Medical Facility
Telephone Number
Address
City
State
Zip Code
Name – Pharmacist or Designee
Telephone Number
I attest that the above named facility is licensed in the State of Wisconsin and is in compliance with all applicable
state and federal laws and administrative rules.
Date Signed
– Pharmacist or Designee
SIGNATURE
NOTICE OF WITHDRAWAL - PHARMACY OR MEDICAL FACILTY
Name – Pharmacy or Medical Facility
Telephone Number
Address
City
State
Zip Code
I attest that, as of
the pharmacy or medical facility identified above, will no longer be participating in
_____
_____
,
(Date)
the Drug Repository Program.
Date Signed
– Pharmacist or Designee
SIGNATURE
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