Prescription Medication Donation Program

Thank you for completing this form attesting to participating in the prescription medication donation program for unexpired prescription drugs.

You must notify the commission in writing if your pharmacy is no longer accepting donated prescription drugs and supplies.

If you have questions, please contact the commission.

Information collected via this form is subject to public disclosure in accordance with chapter 42.56 RCW (Public Records Act).

Facility Name:
Facility Credential(s):
Email:
Phone (enter 10 digit #):

Mailing Address (check if same as physical)

Street1:
Street2:
City:
State:
Zip:

Physical Address

Street1:
Street2:
City:
State:
Zip:

Responsible Pharmacy Manager (RPM):
RPM Credential:
Email:
Phone (enter 10 digit #):
Cell Phone (if applicable):

I attest this pharmacy will participate in the medication donation program as set out in Chapter 69.70 RCW: Access to Prescription Drugs (wa.gov) sections - 020 through - 050 1-4ff and WAC 246-945-488.

Signature (please type name):

Once completed, you may select file and print as a PDF to save your responses.