washington state washington prescription … pmp ucf_v2.pdf · washington. the state of washington...

Washington The State of Washington requires that ALL Prescriptions for Schedule II-V controlled substances be reported to a data repository managed by the Washington Department of Health. PATIENT INFORMATION First Name _____________________________________ MI____ Last Name _________________________________________________ Identification Number Identifier Military ID State Issued ID Unique System ID Passport ID Driver’ s License ID Social Security Number Tribal ID Other Identification Number ____________________________________ DOB _____/_____/__________ Gender Female Male Unknown Species Code 01 Human 02 Veterinarian Patient Address _______________________________________________ City ___________________________ State ____ ZIP ________ DISPENSER INFORMATION Dispenser Name ____________________________________ DEA ______________________________________________________ Phone # (_________)_________-______________ Fax # (_________)_________-______________ Address _______________________________________________ City ___________________________ State _____ ZIP _________ PRESCRIPTION INFORMATION Prescription # ______________________________ NDC Compound Reporting Status New Record Revise Void NDC - - Drug Name (strength) _______________________________________________________ Quantity Dispensed (number of metric units) ______________________ Days Supply ________ Date Written _________________________ Prescriber Name ____________________________________ DEA ________________________ Date Filled _________________________ Refills Authorized __________________________ Refill Number__________________________ Classification Code for Payment Type Private Pay Medicaid Medicare Commercial Insurance Mi litary Installations/VA Workers’ Compensation Indian Nations Other ID of person dropping off or picking up prescription (optional) _________________________________________ Last name and first name of person dropping off or picking up prescription (optional) __________________________________________________ PRESCRIPTION INFORMATION Prescription # ______________________________ NDC Compound Reporting Status New Record Revise Void NDC - - Drug Name (strength) _______________________________________________________ Quantity Dispensed (number of metric units) ______________________ Days Supply ________ Date Written _________________________ Prescriber Name ____________________________________ DEA ________________________ Date Filled _________________________ Refills Authorized __________________________ Refill Number__________________________ Classification Code for Payment Type Private Pay Medicaid Medicare Commercial Insurance Mi litary Installations/VA Workers’ Compensation Indian Nations Other ID of person dropping off or picking up prescription (optional) _________________________________________ Last name and first name of person dropping off or picking up prescription (optional) __________________________________________________ Washington State Prescription Monitoring Program

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Washington

The State of Washington requires that ALL Prescriptions for Schedule II-V controlled substances be reported to a data repository managed by the Washington Department of Health.

PATIENT INFORMATION

First Name _____________________________________ MI____ Last Name _________________________________________________

Identification Number Identifier Military ID State Issued ID Unique System ID Passport ID Driver’s License ID Social Security Number Tribal ID Other

Identification Number ____________________________________

DOB _____/_____/__________ Gender Female Male Unknown

Species Code 01 Human 02 Veterinarian Patient

Address _______________________________________________ City ___________________________ State ____ ZIP ________

DISPENSER INFORMATION

Dispenser Name ____________________________________ DEA ______________________________________________________

Phone # (_________)_________-______________ Fax # (_________)_________-______________

Address _______________________________________________ City ___________________________ State _____ ZIP _________

PRESCRIPTION INFORMATION

Prescription # ______________________________ NDC Compound Reporting Status New Record Revise Void

NDC - -

Drug Name (strength) _______________________________________________________

Quantity Dispensed (number of metric units) ______________________ Days Supply ________ Date Written _________________________

Prescriber Name ____________________________________ DEA ________________________ Date Filled _________________________

Refills Authorized __________________________ Refill Number__________________________

Classification Code for Payment Type Private Pay Medicaid Medicare Commercial Insurance Military Installations/VA Workers’ Compensation Indian Nations Other

ID of person dropping off or picking up prescription (optional) _________________________________________

Last name and first name of person dropping off or picking up prescription (optional) __________________________________________________

PRESCRIPTION INFORMATION

Prescription # ______________________________ NDC Compound Reporting Status New Record Revise Void

NDC - -

Drug Name (strength) _______________________________________________________

Quantity Dispensed (number of metric units) ______________________ Days Supply ________ Date Written _________________________

Prescriber Name ____________________________________ DEA ________________________ Date Filled _________________________

Refills Authorized __________________________ Refill Number__________________________

Classification Code for Payment Type Private Pay Medicaid Medicare Commercial Insurance Military Installations/VA Workers’ Compensation Indian Nations Other

ID of person dropping off or picking up prescription (optional) _________________________________________

Last name and first name of person dropping off or picking up prescription (optional) __________________________________________________

Washington State Prescription Monitoring Program

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