Get the free Pharmacy Naloxone Notification Form - pharmacy ohio

Steven W. Schiphol, Esq. Executive Director John R. Kasich Governor Pharmacy Naloxone Notification Form In an effort to facilitate greater access to naloxone, this notification form will be used to

How to fill out pharmacy naloxone notification form

How to fill out pharmacy naloxone notification form:

1. Obtain the form: Contact your local pharmacy or health department to obtain the pharmacy naloxone notification form. They may provide it physically or offer it for download on their website.
2. Provide personal information: Fill in your full name, address, contact number, and date of birth. This information will be used for record-keeping and to keep track of who has received naloxone.
3. Include emergency contacts: Provide the name and contact information of at least one emergency contact. This could be a family member, friend, or caregiver who can be notified in case of an overdose incident.
4. Identification details: Provide a valid form of identification, such as a driver's license or state ID number. This is usually required to ensure that the naloxone is being distributed to the correct person.
5. Naloxone training: Indicate whether you have received training on naloxone administration. If yes, provide the details of the training program or the organization that conducted the training. If not, inquire about available training options during your visit to the pharmacy or health department.
6. Consent and acknowledgment: Read through the consent and acknowledgment section carefully. This section typically includes information about the risks and benefits of naloxone, as well as the legal responsibilities and limitations associated with its use. If you agree to the terms, sign and date the form.
7. Return the form: After completing the form, return it to the pharmacy or health department as instructed. They will process the form and provide you with naloxone if you are eligible.

Who needs pharmacy naloxone notification form:

1. Individuals at risk of opioid overdose: The pharmacy naloxone notification form is typically required for individuals who are at risk of opioid overdose or their caregivers. This includes people who have a history of opioid use disorder, have received opioid prescriptions, or are in close contact with someone who uses opioids.
2. Caregivers and family members: In some cases, caregivers and family members of individuals at risk of opioid overdose may also need to fill out the pharmacy naloxone notification form. This is to ensure that they are equipped with naloxone and properly trained to respond to an overdose emergency.
3. Specific state requirements: The need for the pharmacy naloxone notification form may vary depending on the state or jurisdiction. Some states have implemented policies that require individuals to complete the form before obtaining naloxone from a pharmacy. It is important to check the requirements of your specific location to determine if the form is necessary.

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What is pharmacy naloxone notification form?

The pharmacy naloxone notification form is a document that pharmacies use to report the dispensing of naloxone, a medication used to reverse opioid overdoses.

Who is required to file pharmacy naloxone notification form?

Pharmacies are required to file the pharmacy naloxone notification form.

How to fill out pharmacy naloxone notification form?

The pharmacy naloxone notification form can be filled out by providing the necessary information about the naloxone dispensing, such as the date, patient information, and prescriber details.

What is the purpose of pharmacy naloxone notification form?

The purpose of the pharmacy naloxone notification form is to track the dispensing of naloxone and gather data on opioid overdoses.

What information must be reported on pharmacy naloxone notification form?

Information such as the date of dispensing, patient's name, prescriber's name, quantity dispensed, and any other relevant details must be reported on the pharmacy naloxone notification form.