Potential Fraudulent Prescription Form to be Completed by the Prescriber

This voluntary form may be used to communicate potentially forged or stolen prescription information to pharmacies/pharmacists in Washington State. Please ensure you verify as much information as possible before you submit this form to confirm your suspicion of fraud. If the situation involves a controlled substance you need to contact the Drug Enforcement Administration (DEA).

The information received will be transmitted by the Commission to pharmacies in Washington. Accuracy of the information is not confirmed or verified prior to transmission.

Information collected via this survey may be subject to release in accordance with RCW 42.56 (Public Records Act).