Note: A sample universal claim form (UCF) is provided on this page to inform dispensers of the data that must be reported to the Washington State Prescription Monitoring Program. This form is provided for informational purposes only and is not to be used for actual data submissions. All data must be electronically submitted using the detailed, step-by-step procedures provided in the WA PMP Dispenser’s Implementation Guide.
 
 
 
 






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Washington State Department of Health

P.O. Box 47852 | Olympia, Washington, 98504-7852

Fax: 360.236.2901