Quarterly Report Form

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

Required Questions
Email address *:
Date of Report *:
Clinic or Pharmacy Name *:
Clinic or Pharmacy Address *:
Name of Contact Person *:
Phone Number *:
Total number of patients receiving repository medications this quarter *:
Total number of units dispensed (total quantity of tablets/capsules/inhalers, etc) this quarter*:

Optional Questions
Were any medications provided to underinsured patients with incomes up to 200% of the Federal Poverty Level?:
If yes, please share information about patient(s) challenges (e.g. high-out-of pocket costs, medications not covered by insurance, claim denied, etc).:
Were any donated medications provided to uninsured patients?:
If yes, please share information about patient(s) challenges (e.g. Medicaid renewal waiting period, no prescription coverage, lost coverage, etc).:
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