Participation Form

11100 Aurora Ave, Bldg. 13 Urbandale, Iowa, 50322
Phone: 1-866-282-5817
Fax: (515) 327-5422
www.safenetrx.org 


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
Name - Pharmacy or Medical Facility:
Email:
Address:
City:
State:
Zip Code:
Iowa License/Registration Number:
Name of Agency/Board Issuing/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

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