Naloxone Standing Order and Portal Registration Form

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

Optionally, if your organization is a qualified entity, you may also request access the naloxone ordering portal.

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.

At this time, the following groups are eligible for this standing order and protocol:

Schools (K-12)
Law Enforcement Agencies
Correctional Facilities
DHS Licensed Programs (Substance use disorder treatment programs, Children's residential substance use disorder treatment programs, Detoxification programs, Withdrawal management programs, Intensive residential treatment services/residential crisis stabilization programs (IRTS/RCS)
Sober Homes
Tribal Nations
Emergency Shelters for People Experiencing Homelessness
Syringe Service Programs

For a more complete and up-to-date list of eligible groups, 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.

Entity Type:

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Entity 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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Shipping Address (Cannot be a PO Box, must be able to sign for packages 9-5, Monday-Friday)

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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Naloxone Portal Access: Ordering Naloxone

Are you also applying for access to the naloxone ordering portal to supply your organization with naloxone?

If you select "Yes" your application will be considered for the ordering portal.

If you select "No" your application will not be considered for the ordering portal but you will still receive the Standing Order and Protocol signed by the MN Department of Health Medical Director.

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Yes

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Briefly describe how naloxone from this program will be used.

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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By checking this box, you certify your organization is one of the approved eligible organizations for this program.

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

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I certify my organization is one of the eligible organizations for this program.

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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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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.