SafeNetRx - Patient Entry

General Information

First Name:

Middle Initial:

Last Name:

Date of Birth:

Telephone:

Address:

Address 1:

Address 2:

City, State Zip:
,

Email Address:

Allergies:

List current medications:

Have you previously been incarcerated or placed under state or local supervision within the past 3 years?
Yes No

Correctional Facility Patient Released From:

Name of Facility:

Booking ID Number:

Patient Attestation – Valid for One Year from Enrollment Date

Residence Information

I hereby attest that I am currently living in the state of Iowa:

Yes No

I hereby attest that I am currently homeless:
Yes No

If you are not homeless, please upload a supporting document showing an Iowa address. (Acceptable documents include Driver's License, State ID, SNAP card, or utility bill showing an Iowa address)

Income Information

I hereby attest that my total estimated annual income from wages and other sources is:

Number of individuals in household:

If income is greater than $0, please upload a supporting document indicating income. (Acceptable documents include tax return, W-2 form, recent paycheck stub, SNAP card, letter from employer showing compensation, etc)

Insurance Information

I am covered by:

Commercial insurance with prescription drug coverage or pharmacy benefits
Veteran’s assistance
Medicare or Medicaid
Any other federal health care program
I do not have health insurance

I lack prescription drug coverage or am unable to afford the prescription co-pay:

Yes No

Authorized by

Electronic Applicant Signature:

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.

Date:

SafeNetRx-Pharmacy HIPAA Notice

Electronic Applicant Signature:

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 safenetrx.org. 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

Date:

SafeNetRx-Pharmacy

Medication Assistance Questionnaire

Registration

General Information

Patient Attestation – Valid for One Year from Enrollment Date

Residence Information

Income Information

Insurance Information

Authorized by

SafeNetRx-Pharmacy HIPAA Notice