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' to complete part one of the registration process. Once submitted, you will see a ‘Registration Success’ page, which will prompt you to print the program’s registration form [PDF]. Print the form and please have the program and clinical directors’ sign the form and email the document to overdose@health.ny.gov

If you have any questions, please call 1.800.692.8528
Thank you

Registration Form