MDHHS Naloxone Request Form
If the Submit Form button does not work, please email the request form
to [email protected] to ensure the form is received.
Naloxone distributed through this portal by the State of Michigan is meant to provide additional naloxone
capacity, beyond existing efforts through the state, the Prepaid Inpatient Health Plans, community
organizations, non-profit organizations, and other channels.
By checking this box, I affirm that my organization will maintain any existing effort, including financial
resources, devoted to naloxone distribution after receiving these doses. These doses will be additional
resources and will not substitute for or displace existing resources provided by my organization. I affirm that
MDHHS is not liable for any claim related to or arising from the distribution or use of the naloxone provided by
MDHHS according to this agreement.
I affirm:
1. Please provide the following information:
3. Number of kits requested (kit requests must be in a quantity of 12):
Please confirm by typing the requested number of kits:
4. Approximate number of clients served by your organization annually:
5. If different, estimate number of clients with opioid use disorder
served by your organization annually:
Please continue to the following page
Organization Name:
Contact Person Name:
Phone Number:
Email Address:
Address Line 1 (for
FedEx delivery):
Address
Line 2:
City, State, Zip:
Type of Organization:
If this request is a re-order from the portal, please indicate the counties targeted for distribution of
this order. Of the previous order, please indicate the number of kits used in the community and, if
known, the number of uses that resulted in overdose reversal:
2. Please very briefly describe your organization's mission and work (50 words):
PLEASE SELECT
12
Submit Form
6. Research suggests that of distributed naloxone kits, approximately 80 – 90 percent of naloxone doses are
administered by individuals actively using substances. Furthermore, risk of overdose is highest among certain
populations, including:
• individuals who have reduced tolerance of opioids (e.g., after leaving incarceration or abstinence-
based treatment; post-partum women who have stopped using; people who have gone through
withdrawal);
• individuals using opioids intravenously;
• individuals who have previously experienced an opioid overdose; and
• individuals using opioids with certain other substances
• individuals with opioid use disorder and complex co-occurring medical conditions.
Please describe specifically how your organization will distribute these doses to individuals at highest risk of
overdose (100 words):
7. Please describe your organization’s past or current efforts to distribute naloxone to high-risk populations,
including any data collected around kits distributed and overdose reversals reported (100 words):
All requests are subject to approval by MDHHS. Completion of this
form does not guarantee that the product will be provided to the
organization or in the amounts requested.
Naloxone provided by MDHHS is done so under the Naloxone Standing Order. For
more information, please refer to
http://www.legislature.mi.gov/documents/2015-2016/publicact/pdf/2016-
PA-0383.pdf
Educational Resources can be viewed and downloaded at the following links:
https://www.narcan.com/patients/patient-resources
https://www.narcan.com/first-responders/law-enforcement-roll-call-video
https://beawarebeprepared.com/resources/
If your entity wishes to obtain printed copies of these educational resources and/
or demonstration/training devices, please submit a request via email to
8.
MDHHS is utilizing the smartphone app OpiRescue to connect naloxone recipients to harm reduction and
treatment resources and collect overdose reversal data. Please select the following from the dropdown menu:
PLEASE SELECT
