Skip Navigation LinksNaloxone-Application

Safe and active communities (SAC) Branch

Naloxone Standing Order Application

 Instructions

Complete the application below. Please ensure the person applying is authorized to be the representation of your organization to apply for and receive this standing order. The information submitted in this application should be publicly accessible information and may be subjected to the Public Records Act. After submitting the application information below, a copy of the statewide standing order will be issued to the applicant. If, after submitting your application, you do not receive a standing order, please contact NaloxoneStandingOrder@cdph.ca.gov

You must certify and agree to the information in this section to receive a standing order.

State
CA

 Terms and Conditions

By submitting the online application form, the entity:

 1.    Certifies that the contact and location information provided is correct.

 2.    Will ensure that any of its affiliates or subcontractors apply for their own standing order.

 3.    Agrees to allow the California Department of Public Health to contact the entity using the information provided on the application form.

 4.    Agrees to allow the California Department of Public Health to use the information provided on the application form to track the use of the standing order and conduct other public health and epidemiological surveillance activities.

 5.    Acknowledges that the standing order cannot be used to purchase or sell naloxone.

 6.    Agrees to ensure that entities and individuals receiving and administering naloxone receive opioid overdose prevention and treatment training as defined.

 7.    Agrees to maintain and report, at the time of renewal, information regarding the number of doses of naloxone distributed under this standing order.

 8.    If known/available, agrees to maintain and report information, upon renewal, regarding the number of reversals that occurred using naloxone distributed under this standing order.

 9.    Agrees to re-register for the standing order if there is a change in the information required on this form.

10.    Agrees to maintain a copy of the standing order, which will include these terms and conditions.

 Expiration, Renewal and Review

The standing order will automatically expire one year from the date that it is signed by the State Health Officer or on the date that the physician whose signature is on the standing order has ceased acting as the State Health Officer, whichever comes sooner. The standing order can be renewed by completing another online application form. The standing order should be reviewed carefully against the most current recommendations, and may be revised or updated if there is new information about naloxone administration.
Page Last Updated :