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Naloxone Application

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

First Name of Authorized Person Middle Last Name Suffix Are you applying to renew your statewide standing order?

Approximately how many doses of naloxone have you distributed using the standing order? Approximately how many opioid overdose reversals can you attribute to the doses of naloxone you distributed using the standing order?

You must certify and agree to the information in this section to receive a standing order. Solve the captcha to validate you are human if it appears.

I hereby certify that the information provided on this application form is correct. I hereby certify that I have read, understand, and accept all the terms and conditions under which the standing order is valid for use below.

Entity Name Type of Entity If "Other" is selected, please specify Physical Address Address Line 2

City

State
CA

Entity Zip Code Zip Code(s) of the service area(s) served (you can distribute beyond the Zip Codes provided) Public Phone Number Public Email Address

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

This standing order will automatically expire two years from the date that it is signed. The standing order can be renewed by completing another online application form. This 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.

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Naloxone Standing ORder Application

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Terms and Conditions

Expiration, Renewal and Review