Bicillin® Request Form

As of July 11, 2025, Bicillin® is being prioritized for pregnant individuals due to a manufacturer shortage. Requests for individuals who are not pregnant will be considered as supply allows.


This form is for providers/clinics to request Bicillin® for treatment of syphilis.


Instructions for requesting Bicillin® for treatment of a confirmed syphilis case and/or sex partner:


  1. Confirm the patient or sex partner(s) meet the Centers for Disease Control and Prevention (CDC) 2021 STI Treatment Guidelines.
  2. Fill out and submit this Bicillin® Request Form.
  3. Fax the following documents to Clark County Public Health (CCPH) at 564.397.8080 (confidential fax):
  4. Confirmatory test and positive RPR lab results,
  5. CCPH STI Case Report,
  6. STI visit chart notes (facilities exempt from this: Kaiser, Legacy, PeaceHealth, Providence, OHSU, Sea Mar, and Vancouver Clinic)
  7. Bicillin® delivery:
  • CCPH staff will deliver the Bicillin® dose(s) to your clinic and it must be received by a licensed staff (MA, LPN, RN etc.) and placed in refrigerated storage.
  • Medication must be kept between 2°- 8°C or 36º- 46ºF.
  • An email confirming receipt of delivery will be sent to the provided email address once delivery has been completed.


IMPORTANT NOTES:


  • Providers have 3 days from diagnosis to complete and fax a CCPH STI Case Report.
  • There are no age or gender restrictions for a confirmed or suspected syphilis case to have Bicillin® supplied by CCPH.
  • Bicillin® received by the clinic is to be used only on the intended patient.
  • CCPH can supply but will not administer the Bicillin®.
  • Since Bicillin® is provided free of charge by CCPH, clinics may not charge for it. However, clinics may charge for administering the injection.
  • Unused Bicillin® must be returned. CCPH staff should be contacted to arrange a return by phone at 564.397.8082 or by emailing STDProgram@clark.wa.gov.
 
 
 
 
 
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Bicllin® is delivered on the day of the appointment.


In order to properly plan for delivery, please submit this request as soon as an appointment is scheduled. If you have an an urgent request, please submit this form and call 564-397-8082, in order to discuss with a CCPH staff member.

 
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Please provide the best way to reach you (cell, backline, etc.).

Phone
 

A delivery receipt will be sent to this email once the Bicillin® is delivered to the clinic.

 
 

I have faxed/I will fax all associated syphilis lab results and a completed Case Report to CCPH at 564.397.8080 (confidential fax).

 

I have faxed/I will fax all related STI visit chart notes to CCPH at 564.397.8080 (confidential fax).

Facilities exempt from this: Kaiser, Legacy, PeaceHealth, Providence, OHSU, Sea Mar, and Vancouver Clinic.

 

Upon delivery, a licensed staff (MA, LPN, RN etc.) will be available to receive the medication and place in refrigerated storage.