Opioid Overdose Program Registration Registration

Agency/Organization Name:

County:

Address:

City:
Zip:

Agency/Facility Classification:

Facility:

*

Hospital
Diagnostic & Treatment
Drug Treatment Program

Government Agency:

*

Local-Schools
Local-Health
Local-Public Safety
Local-Other
State

Practitioner:

*

License#:

Date:

Exp:

Physician
Nurse Practitioner
Physician Assistant

Organization:

College/University/Trade School
Community-Based Organization

Program Director:

Program Director Title:

Phone:

Ext:

Alt Phone:

Ext:

Email:

Program Director Address: Same as Agency/Organization

City:

Zip:

Clinical Director:

Clinical Director Title:
Clinical Director Address: Same as Program Director

City:

Zip:

License:

Physician
Nurse Practitioner
Physician Assistant

NYS License #:

License Date:

Expire:

Phone:

Ext:

Email:

Optional Additional Users: click "plus" to optional additional users

The primary counties targeted for overdose activities are:

1: 2: 3: 4: 5: 6: 7:

Targeted Responder Outreach/Recruitment Strategy:

Affiliated Prescribers click "plus" to add more Affiliated Prescribers None

Name:

Practioner:

Physician
Nurse Practitioner
Physician Assistant

NYS License #:

License Date:

Expire:

Opioid Overdose Prevention Program Sites

click "plus" to add more Program Sites Site same as agency

Program Name:

Directory Point Person:
Address:

City:

Zip

Phone Number for Directory:

Ext:

List in Directory:

Ship To Address for Site:

Ship To Name:
Ship To Email:

Ship To Address: Same as site

Ship To City:

Ship To Zip

Click 'submit' when the application is complete. Program and clinical directors will receive a confirmation email with a link requiring their electronic signature and review.

Submission of this application does not guarantee or register an entity to become registered as an overdose program or access naloxone rescue kits. Please email the team with any questions or updates to the application, etc. at overdose@health.ny.gov or 1.800.692.8528 Thank You.

Application: Register to become an overdose prevention program.

Agency/Facility Classification:

Facility:

Government Agency:

Practitioner:

Organization:

License:

The primary counties targeted for overdose activities are:

Targeted Responder Outreach/Recruitment Strategy:

Affiliated Prescribers click "plus" to add more Affiliated Prescribers None

Name:

Practioner:

Opioid Overdose Prevention Program Sites

Ship To Address for Site: