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(California pharmacists do not need to use the standing order. Pharmacists can dispense naloxone without a prescription from a health care provider as authorized and in compliance with Business and Profession Code Section 4052.01.)

Terms and Conditions

To obtain the standing order, each entity must provide all of the following:

1.     Name of the authorized person completing the application form on behalf of the entity (first, middle, and last name, and if applicable, suffix)

2.     Email address for the person completing the application form

3.     Entity Information

a.     Name of the entity that is requesting the standing order

b.     Type of entity

c.     Physical address

d.     Public phone number

e.     Public email address

f.      ZIP code(s) of the service area(s) served

By submitting the online application form, the entity:

 1.    Certifies that the contact and location information provided is correct.

 2.    Will ensure that any of its affiliates or subcontractors apply for their own standing order.

 3.    Agrees to allow the California Department of Public Health to contact the entity using the information provided on the application form.

 4.    Agrees to allow the California Department of Public Health to use the information provided on the application form to track the use of the standing order and conduct other public health and epidemiological surveillance activities.

 5.    Acknowledges that the standing order cannot be used to purchase or sell naloxone.

 6.    Agrees to ensure that entities and individuals receiving and administering naloxone receive opioid overdose prevention and treatment training.

 7.    Agrees to maintain and report, at the time of renewal, information regarding the number of doses of naloxone distributed under this standing order.

 8.    If known/available, agrees to maintain and report information, upon renewal, regarding the number of reversals that occurred using naloxone distributed under this standing order.

 9.    Agrees to re-register for the standing order if there is a change in the information required on this form.

10.    Agrees to maintain a copy of the standing order, which will include these terms and conditions.

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