LICENSED HEALTH CARE PROVIDER WITH PRESCRIBING AUTHORITY Complete this section IF your – Overdose Response Program intends to provide naloxone. Name: Title: Address: Email: City, Zip Phone: Fax: State License Expiration Number: Date: The Provider will: Please indicate the provider’s role in training by selecting all that apply. Conduct Training Prescribe and dispense naloxone Attach a signed copy of your Licensed Supervise Trainers If selected Health Care Provider Agreement → This practitioner’s license is active: Yes No The practitioner may NOT conduct – trainings or supervise trainers and ORP This practitioner’s license has been suspended or revoked and reinstated No Yes Provide an explanation below within the past 5 – There is an active investigation and/or pending disciplinary charges against No this practitioner: Yes Provide an explanation below – I certify that the information provided in this application is complete and accurate to the best of my knowledge SIGNATURE Provider’s signature: Date: ORP Application Checklist/FAX Cover Page TO: DHMH NALOXONE
LICENSED HEALTH CARE PROVIDER WITH PRESCRIBING AUTHORITY – Complete this section IF your Overdose Response Program intends to provide naloxone. Name: Title: Address: City, Zip Email: Phone: Fax: State License Number: Expiration Date: The Provider will: Please indicate the provider’s role in training by selecting all that apply. Conduct Training Supervise Trainers Prescribe and dispense naloxone If selected → Attach a signed copy of your Licensed Health Care Provider Agreement This practitioner’s license is active: Yes No – The practitioner may NOT conduct trainings or supervise trainers and ORP This practitioner’s license has been suspended or revoked and reinstated within the past 5 No Yes – Provide an explanation below There is an active investigation and/or pending disciplinary charges against this practitioner: No Yes – Provide an explanation below I certify that the information provided in this application is complete and accurate to the best of my knowledge SIGNATURE Provider’s signature: Date: ORP Application Checklist/FAX Cover Page TO: DHMH NALOXONE