Part 3, Chapter 35: Manual Exhibit 3-35-B

Manual Exhibit 3-35-B

This serves as the Standing Order authorizing the dispensing and administration of Naloxone as indicated below:

1. The Indian Health Service (IHS) facility, _____________________________________, is authorized to dispense Opioid Overdose Toolkits to trained first responders for emergency use.
2. The toolkit contains:
   1. ________ doses of naloxone for to be given by _______________ route of administration
   2. The toolkit additionally incudes: _____________________________________________
3. Trained first responders are authorized to administer Naloxone to individuals whom they believe in good faith are suffering from opioid overdose.

Medical Control Provider

Name: ____________________

IHS Facility: ____________________

Address: ____________________

____________________

Phone Number: __________________ Fax Number: __________________

Medical Control Provider Signature: ___________________________ Date: ________

Return form to:

Name: ____________________

IHS Facility: ____________________

Address: ____________________

____________________

Phone Number: __________________ Fax Number: __________________