Get the free MDHHS Naloxone Request Form - State of Michigan

MD HHS EMS Naloxone Request Resubmit FormReturn completed form by email to MDHHSNalxneRqst@michigan.govNaloxone distributed through this portal by the State of Michigan is meant to provide additional

How to fill out mdhhs naloxone request form

How to fill out mdhhs naloxone request form

1. Obtain a copy of the MDHHS Naloxone Request Form from the MDHHS website or from a local health department.
2. Fill out the patient information section with the required details, including name, date of birth, and contact information.
3. Provide information on the requester, including the name of the individual or organization making the request.
4. Indicate the quantity of naloxone being requested and the preferred type (nasal spray, auto-injector, etc.).
5. Sign and date the form, certifying that the information provided is accurate and that the naloxone will be used for emergency overdose response.

Who needs mdhhs naloxone request form?

1. Individuals who are at risk of experiencing or witnessing an opioid overdose.
2. Healthcare professionals who may need to administer naloxone in emergency situations.
3. Community organizations providing support to individuals with substance use disorder.

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What is mdhhs naloxone request form?

The mdhhs naloxone request form is a form used to request naloxone, a medication used to reverse opioid overdoses, from the Michigan Department of Health and Human Services.

Who is required to file mdhhs naloxone request form?

Any organization or individual seeking to obtain naloxone from the Michigan Department of Health and Human Services is required to file the mdhhs naloxone request form.

How to fill out mdhhs naloxone request form?

The mdhhs naloxone request form can be filled out online on the Michigan Department of Health and Human Services website. The form requires information about the requesting organization or individual, as well as the intended use of the naloxone.

What is the purpose of mdhhs naloxone request form?

The purpose of the mdhhs naloxone request form is to ensure that naloxone is distributed appropriately and equitably to those who need it, in order to prevent opioid overdoses.

What information must be reported on mdhhs naloxone request form?

The mdhhs naloxone request form requires information about the requesting organization or individual, including contact information, intended use of the naloxone, and previous experience with naloxone administration.