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Central Valley Health DistrictOpioid Overdose/ Refill Form Name: Signature: Date: / / 1.a. Was naloxone () administered to reverse an overdose? Yes (Skip to 2.) No (complete 1.b., below)1.b. What

How to fill out opioid overdose refill form

How to fill out opioid overdose refill form

1. Start by providing your personal information such as name, address, contact number, and date of birth.
2. Fill out the section that asks for your healthcare provider's information, including their name, address, and contact details.
3. Specify the type of opioid medication that you need a refill for, along with the dosage and frequency of use.
4. Indicate the reason for needing the refill, whether it is due to running out of medication or any other valid reason.
5. If you have any allergies or medical conditions that your healthcare provider should be aware of, make sure to mention them in the appropriate section.
6. Sign and date the form to certify that the information provided is accurate and complete.
7. Submit the completed form to your healthcare provider or the designated authority for processing.

Who needs opioid overdose refill form?

1. Individuals who are prescribed opioid medications and require a refill can use the opioid overdose refill form.

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What is opioid overdose refill form?

The opioid overdose refill form is a document used to request additional doses of medication, such as naloxone, that can reverse opioid overdoses. It is typically filled out by healthcare providers or pharmacists.

Who is required to file opioid overdose refill form?

Healthcare providers, pharmacists, and in some cases, individuals or organizations administering opioid overdose prevention programs are required to file the opioid overdose refill form.

How to fill out opioid overdose refill form?

To fill out the opioid overdose refill form, the requester needs to provide information such as patient details, previous prescription information, the quantity requested, and the provider's signature.

What is the purpose of opioid overdose refill form?

The purpose of the opioid overdose refill form is to ensure that there is a legal and documented process in place for obtaining additional doses of life-saving medications to treat opioid overdoses.

What information must be reported on opioid overdose refill form?

The form must report information including patient name, prescription details, quantity requested, and possibly the reason for the refill, along with the provider's information.