Medication Assistance Questionnaire

Phone: 515.276.0066
Toll Free: 1.866.282.5817
Fax: 515.401.1191

Note: we do not dispense prescriptions for controlled substances or for those that require refrigeration.


General Information

Address 1:

Address 2:

City, State Zip:


Patient Attestation – Valid for One Year from Enrollment Date

Residence Information

(Acceptable documents include Driver's License, State ID, SNAP card, or utility bill showing an Iowa address)

Income Information

(Acceptable documents include tax return, W-2 form, recent paycheck stub, SNAP card, letter from employer showing compensation, etc)

Insurance Information

Authorized by
I certify that all of the above information is true and correct as of the date shown below. I understand that this information is to be used to determine eligibility for donated medications and that any misrepresentation herein will terminate my ability to receive medications from SafeNetRx-Pharmacy. I will notify SafeNetRx of any changes in employment, income or insurance prior to having additional prescriptions filled. I acknowledge that I may not seek payment from any third-party payer, including federal health care programs such as Medicaid or Medicare, for any Program Products received from SafeNetRx.

SafeNetRx-Pharmacy HIPAA Notice
I authorize release of any medical information necessary for audit purposes to program administrators or third-party designees to verify eligibility for medication donation programs, or to process this (these) claim(s) by third-party payors and permit the following to be used in place of this original document for all federal, state, commercial, compensation, or liability third-party claims:
(1) a photocopy of other facsimile reproduction of this authorization, or
(2) use of a computer to indicate my signature is on file, and/or use of a computer to electronically transmit my claim for processing.
I understand I have a right to review SafeNetRx’s Notice of Privacy Practices prior to signing this document. SafeNetRx’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of SafeNetRx on SafeNetRx’s website at This Notice of Privacy Practices also describes my rights and SafeNetRx duties with respect to my protected health information. SafeNetRx reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing SafeNetRx’s website or calling the office and requesting a revised copy be sent in the mail.
SafeNetRx Notice of Privacy Practices