Quarterly Report Form

1500 SE 19th Street, Suite 530, Grimes, IA 50111
Phone: 1-866-282-5817
Fax: (515) 327-5422
www.safenetrx.org

Date of Report:

Clinic or Pharmacy Name:

Clinic or Pharmacy Address:

Name of Contact Person:

Contact Email:

Contact Phone Numer:

Total number of patients that received donated medications this quarter:

Total number of donated units dispensed (total quantity of tablets/capsules/inhalers, etc.):



Optional Questions to help SafeNetRx document the impact of the Drug Donation Repository Program:
Were any donated medications dispensed to UNDER-INSURED patients with incomes up to 200% of the Federal Poverty Level?:

If yes, please share information about patient(s) challenges, for example high out-of-pocket costs, medication not covered by insurance, claim denied:

Were any donated medications dispensed to UNINSURED patients?:

If yes, please share information about patient(s) challenges, for example Medicaid renewal waiting period or no prescription coverage:

SafeNetRx is a 501(c)3 non-profit organization with a mission to solve medication inequity through responsible collection and distribution of donated medicines.

SafeNetRx

1500 SE 19th St, Ste 530, Grimes, IA 50111

Phone: 1-866-282-5817
Fax: 515-327-5422
Email: repository@safenetrx.org

About Us

Our Team

Drug Donation Repository

Charitable Pharmacy

Website by Morweb.org

Quarterly Report Form

Optional Questions to help SafeNetRx document the impact of the Drug Donation Repository Program: