Participation Form

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

Name - Pharmacy or Medical Facility:

Iowa Drug Donation Repository Program Notice of Participation to Dispense
Completion of this form meets the notification requirement to prescribe and/or dispense prescription medications as part of the prescription drug donationrepository program under Iowa Administrative Code 641—109.3. Questions about completing this form may be directed to kenzie.harder@safenetrx.org.

Pharmacy or Medical Facility

Email:

Address:

City:

State:

Zip Code:

Iowa License/Registration Number:

Name of Agency/Board Issuing the Registration Number:

Name - Pharmacist, Physician, Nurse Practitioner, Program Manager:

Telephone Number:

I certify the above named facility is in compliance with all state and federal laws and administrative rules and will comply with the requirements ofthis chapter. Further, I certify that if repository medications are taken off site for any purpose they will be transported in a manner that is secure and environmentally controlled.

Will repository medications be taken off site?:

*Drugs and biological products for which the Federal Food and Drug Administration (FDA) requires a Risk Evaluation and Mitigation Strategy (REMS) with an element to assure safe use OR an implementation system, and such drugs and biological products as determined by the pharmacist in charge, shall not be accepted or distributed under the provisions of the program.

Signature - Pharmacist, Physician, Nurse Practitioner, Program Manager:

Date:

Primary Contact Information
Name of Primary Contact for Drug Donation Program Communication:

Primary Contact Phone Number

Primary Email Address:

Primary Contact Fax Number

By checking this box you have read our program rules here

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

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Participation Form

Iowa Drug Donation Repository Program Notice of Participation to Dispense

Pharmacy or Medical Facility

Primary Contact Information