641—109.3 (135M) Eligibility criteria for program participation by medical facilities and pharmacies.
	 109.3(1) To be eligible for participation in the prescription drug donation repository program, a medical facility or pharmacy shall be in compliance with all applicable federal and state laws, including laws applicable to the storage and distribution of drugs and the appropriate licensure standards, and shall hold active, nonrestricted, state-issued licenses or registrations in good standing.
	 109.3(2) Participation in the prescription drug donation repository program is voluntary.
	 109.3(3) A pharmacy or medical facility may elect to participate in the prescription drug donation repository program by providing, on a form prescribed by the department and available on the program’s Web page, written notification to the centralized repository of all of the following:
	  a.   	 The name, street address, and telephone number of the pharmacy or medical facility, and any state-issued license or registration number issued to the pharmacy or medical facility, including the name of the issuing agency.
	  b.   	 The name and telephone number of the responsible pharmacist, physician or nurse practitioner who is employed by or under contract with the pharmacy or medical facility.
	  c.   	 A statement, signed and dated by the responsible pharmacist, physician or nurse practitioner, indicating that the pharmacy or medical facility meets the eligibility requirements under this rule and shall comply with the requirements of this chapter.
	 109.3(4) Withdrawal from participation. A pharmacy or medical facility may withdraw from participation in the prescription drug donation repository program at any time by providing written notice to the centralized repository on a form prescribed by the department and available on the program’s Web page.