Before accepting a donated prescription drug under this chapter, a recipient shall sign a form prescribed by the department stating that:
(1) the recipient acknowledges that if the donor is an individual, prescription drug manufacturer, or health care facility other than a pharmacy, the donor is not a pharmacist and the donor took ordinary care of the prescription drug;
(2) the recipient acknowledges that the donor is known to the participating provider and that there is no reason to believe that the prescription drug was improperly handled or stored;
(3) by accepting the prescription drug, the recipient accepts any risk that an accidental mishandling could create; and
(4) the recipient releases the donor, participating provider, and manufacturer of the drug from liability related to the prescription drug.