(b) The resident’s name and dated signature, or the name and dated signature of the
resident’s representative or guardian.
(c) Attestation to the following statement, “As the legal owner of the listed prescription
drug(s), I agree to voluntarily donate the listed eligible unused drugs to the program for
utilization of unused prescription drugs.”
(d) The drug brand name or generic name, the name of manufacturer or national drug code
number (ndc#), the quantity and strength of the drug, and the drug’s expiration date.
(e) The date of the donation.
(f) The name, address, telephone number and state of Michigan license or registration
number of the pharmacy or charitable clinic receiving donated unused prescription drug.
(g) The date the donated drugs are received by the pharmacy or charitable clinic.
(h) The name, state of Michigan license or registration number, and dated signature of the
authorized pharmacist or health care provider receiving the donated prescription drug.
(3) The eligible participant form shall include all of the following information:
(a) The participating pharmacy’s or charitable clinic’s name, address, telephone number,
state of Michigan license or registration number, and the name, state of Michigan license or
registration number, and dated signature of dispensing pharmacist.
(b) The drug’s brand name or generic name, the name of manufacturer or national drug code
number (ndc#), the quantity and strength of the drug, the date the drug was dispensed, and the
drug’s expiration date.
(c) The eligible participant’s name, date of birth, address, and dated signature.
(d) Attestation of all of the following:
(i) The eligible participant is a resident of this state.
(ii) The eligible participant is eligible to receive medicare or medicaid or is uninsured and
does not have prescription drug coverage.
(e) The eligible participant acknowledges that the drugs have been donated.
(f) The eligible participant consents to a waiver of the requirement for child resistant
packaging, as required by the poison prevention packaging act, being 15 U.S.C. §1471−1477.
(4) The transfer form shall include all of the following information:
(a) The eligible facility or manufacturer’s name, state of Michigan license or registration
number, address, telephone number, and the name, dated signature, and state of Michigan license
number of the responsible pharmacist.
(b) The date of donation.
(c) The drug’s brand name or generic name, the name of manufacturer or national drug code
number (ndc#), the quantity and strength of the drug, and the drug’s expiration date.
(d) The pharmacist of the eligible facility or manufacturer shall attest to the following
statement, “I certify that the prescription drugs listed on this form for donation are eligible for
donation and meet the requirements for prescription drugs under the program, including any
storage requirements.”
(e) The receiving participating pharmacy’s or charitable clinic’s name, address, and
telephone number, and name and state of Michigan license number of responsible pharmacist
authorized to receive the donation.
(f) The responsible pharmacist shall sign and date the transfer form attesting to the
following statement, “Upon receipt and inspection of the above listed donated prescription drugs,
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