Naloxone Standing Order Registration and Renewal Form

Please complete the form below to enter into the naloxone standing order and protocol with the State of Minnesota.

The purpose of this form is for organizations in Minnesota to register for a Standing Order with the Minnesota Department of Health in order to request, obtain, distribute, and administer naloxone, more commonly known as Narcan, a prescription drug that reverses opioid overdoses.

For a complete and up-to-date list of eligible groups for the naloxone ordering portal, please visit: Naloxone Standing Order and Portal - MN Dept. of Health (state.mn.us)

By completing this form, you are requesting to participate in the Naloxone Standing Order and Protocol with the Minnesota Department of Health.

When you complete this form and click "submit", you will be brought to page with a link to the official Standing Order and Protocol document. Please save a copy of this document for your organization's records.

Organization Type Primary Group

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Community Organization Secondary Group

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Law Enforcement/EMS Secondary Group

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Hospital Secondary Group

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Government Agency Secondary Group

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Education Secondary Group

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Substance/Mental Health Clinics Secondary Group

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Other Secondary Group

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Organization Name:

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Primary Contact Information

Important: The primary contact information must be the same information used when applying to and accessing the naloxone ordering portal. If information does match it can delay your ability to order naloxone.

First Name:

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Last Name:

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Organization Address

Address 1:

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Address 2:

City:

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County:

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State:

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Zip:

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Phone:

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Email:

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Briefly describe how naloxone will be used at your organization.

Examples of this could include: Will it be used to comply with a state mandate? Will it be used for staff to carry? Will it be distributed to overdose victimes or their friends & family? Will it be strategically placed around your organization building? Will it be made available to the public?

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Training and Education
By checking this box, you acknowledge to provide training and education to staff within your organization who will carry, purchase, distribute, or administer naloxone. This training may include web-based, written, and in-person instruction.

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I Acknowledge

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Policies and Procedures

By checking this box, you acknowledge that you currently have or will develop policies and procedures for activities related to the purchase, distribution, and administration of naloxone as a part of your organizational capacity.

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I Acknoweldge

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Quality Improvement

Are you willing to participate in evaluation efforts in the future to help us improve this program?

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Yes

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