Registration Form


 
 
 


Agency/Facility Classification:  

Facility:

*

Government Agency:

*

Practitioner:

*

Organization:


 






 



 

 



License:




 




 click "plus" to optional additional users

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 

 click "plus" to add more Program Sites  









 

Ship To Address for Site:



  Same as site



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.