Section R4-23-1206. Recipient Form

Before receiving a donated prescription medication from the pre- scription medication donation program, a recipient of a donated prescription medication shall sign a form:

1.        Identifying the physician’s office, pharmacy, or health care institution that is dispensing the donated prescription medication;

2.        Stating that the recipient has been advised of and under- stands the immunity provisions of the program under

A.R.S. § 32-1909(E) and (F);

3.        Attesting that the recipient meets the eligibility require- ments specified in R4-23-1204: and

4.        Including the following:

a.         The brand name or generic name of the prescription medication received;

b.        If a generic medication, the name of the manufac- turer or the national drug code number of the pre- scription medication received;

c.         The   strength   of   the    prescription   medication received;

d.        The   quantity    of   the    prescription   medication received;

e.         The recipient’s name and address; and

f.         The dated signature of the recipient.

Historical Note

New Section made by final rulemaking at 14 A.A.R.

4320, effective January 3, 2009 (Supp. 08-4).