To get started, complete the Patient Application Form. For prospective products, the physician must complete the Product Prescription Form or submit an original script. For replacement products, the facility must first enroll in The Safety Net Foundation. The facility can then submit requests for replacement product using the product replacement request form.
Institutions that have enrolled as Individual Patient Assistance Program (IPAP) facilities may use the IPAP Patient Application to enroll their patients.
Forms revised October 1, 2013. Previous versions of the application can no longer be accepted after January 1, 2014.
Once a completed application and any required supporting documents have been received and processed, the patient and provider will be notified of the enrollment decision. Missing information or an incomplete application will delay an enrollment decision.