Free Cancer Drug Repository Program Notice of Participation or Withdrawal, F-62643 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62643 (Rev. 07/08)

STATE OF WISCONSIN

CANCER DRUG REPOSITORY PROGRAM NOTICE OF PARTICIPATION OR WITHDRAWAL
Completion of this form meets the notification requirement for participation in, or withdrawal from, the Cancer Drug Repository Program under Chapter HFS 148.04(2) and (3), Wis. Admin. Code. Complete and submit this form to the following address: Cancer 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 cancer 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)
Name ­ Pharmacy or Medical Facility Address City Name ­ Pharmacist or Designee State Zip Code

Partial Participation (Will not dispense drugs and supplies)
Telephone Number

Telephone Number

I attest that the above named facility is licensed in the State of Wisconsin and is in compliance with all state and federal laws and administrative rules.
SIGNATURE ­ Pharmacist or Designee
Date Signed

NOTICE OF WITHDRAWAL - PHARMACY OR MEDICAL FACILTY
Name ­ Pharmacy or Medical Facility Address City State Zip Code Telephone Number

I attest that, as of _____
(Date)

_____ , the pharmacy or medical facility identified above, will no longer be participating in

the Cancer Drug Repository Program.
SIGNATURE ­ Pharmacist or Designee
Date Signed