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Department of Public Health and Human Services Naloxone Order Form 5032606 MCA An eligible recipient who distributes an opioid antagonist shall fulfill the basic instruction and information requirements
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How to fill out naloxone order form
How to fill out naloxone order form
01
To fill out a naloxone order form, follow these steps:
02
Obtain a naloxone order form from a healthcare provider or a pharmacy.
03
Fill in your personal information, including your name, date of birth, and contact information.
04
Provide your healthcare provider's information, including their name, address, and contact information.
05
Indicate the number of naloxone kits you need and any specific instructions or preferences.
06
Sign and date the form.
07
Return the completed form to the healthcare provider or pharmacy.
08
Follow any additional instructions provided by the healthcare provider or pharmacy.
Who needs naloxone order form?
01
Anyone who is at risk of opioid overdose or who wants to be prepared to help someone experiencing an opioid overdose may need a naloxone order form.
02
This includes individuals who use opioids, individuals who have a history of opioid overdose, friends or family members of individuals at risk, and community organizations or programs that provide opioid overdose prevention services.
03
Naloxone is a life-saving medication that can reverse the effects of an opioid overdose, and having access to it can make a significant difference in saving lives.
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What is naloxone order form?
The naloxone order form is a document used to request naloxone, a medication used to reverse opioid overdoses.
Who is required to file naloxone order form?
Healthcare providers or organizations authorized to dispense naloxone are required to file the naloxone order form.
How to fill out naloxone order form?
The naloxone order form must be completed with all required information, such as patient details, prescriber information, and quantity needed.
What is the purpose of naloxone order form?
The purpose of the naloxone order form is to ensure that naloxone is distributed safely and appropriately for opioid overdose reversal.
What information must be reported on naloxone order form?
The naloxone order form must include patient name, prescriber information, quantity of naloxone needed, and any specific instructions.
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