Free Cancer and Chronic Diseases Drub Repository Program Recipient Record-F-62645 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62645 (Rev. 07/08)

STATE OF WISCONSIN

CANCER AND CHRONIC DISEASES DRUG REPOSITORY PROGRAM RECIPIENT RECORD


Completion of this form meets the requirement of Wisconsin Administrative Code HFS 148.07(3) for dispensing drugs or medical supplies to recipients who meet the eligibility requirements of HFS 148.05. Questions about completion of this form may be directed to 608-266-5388.
Date Received

Name ­ Recipient (Print or type.)

NOTE: The pharmacy may place a copy of the label on this form in lieu of entering the following information.
Name ­ Medication Medication Strength Expiration Date Quantity Received

I attest that I am a Wisconsin Resident and that I understand that the medication I am receiving has been donated and has potentially been stored in a non-controlled environment. I understand that the pharmacy, pharmacist, and manufacturer cannot be held liable for problems with this medication that has been accepted for donation and dispensed in good faith.
SIGNATURE ­ Recipient
Date Signed