NALOXONE INTEREST FORM

Naloxone (NARCAN) Interest Form

Throughout the years, Skippack Pharmacy has been committed to being a pillar of healthcare for our community, from immunizations to weight loss medications, and now, preventive health measures. Skippack Pharmacy is proud to be launching its Naloxone Program where you can receive FREE** Naloxone. Naloxone nasal spray is a medication that is designed to rapidly reverse the effects of an opioid (narcotic medication) overdose, which is a life-threatening situation. Overdoses from opioid medications occur by the thousands each week, and too many lives are lost to not having access to life-saving medications. ANYONE can be at risk of opioid overdose for multiple reasons, including use of prescription medications, accidental ingestion, and other factors. This form will ask you a few questions regarding your interest in Naloxone and collect health information needed to process the prescription through insurance and/or state programs.
**By utilizing the PACE Assistance Program, Skippack Pharmacy is able to process Naloxone prescriptions through a patient's insurance with a $0 copay to the patient. In the event that Naloxone is not covered under a patient's insurance OR an individual is uninsured, Skippack Pharmacy has your back and will provide Naloxone at no cost to the patient.
Let's learn a little more about you!

We may know some of you, and we may not know others.. we welcome ALL patients and/or businesses who are interested in learning more about Naloxone and it's life-saving measures! We love having the opportunity to serve anyone in our community, but we need a little more information first.This form is HIPAA protected and the information collected will not be shared with any individual or organization outside of Skippack Pharmacy. The information below will solely be used to process the claim to ensure that you can receive this life-saving medication at no cost!
Who is filling out this form?*

I am filling out this form for myselfI am filling this form out for a spouse, family member, or significant otherI represent a First Responders Company/Organization/GroupI represent a Local Business, Shop, Restaurant, CompanyI represent an Organization or Non-ProfitI represent a Governmental OfficeOther
Patient Status with Skippack Pharmacy*

I currently use and/or have used Skippack Pharmacy for prescriptionsI have received immunizations and/or testing from Skippack PharmacyI haven't been to Skippack Pharmacy before but I want to learn to save a life!I am filling this out as a representative of a company/business/organization/etc.
How did you hear about Skippack or our Naloxone program?
Patient Information

Please fill this section of the form out IF AND ONLY IF you are requesting naloxone as a patient or for a spouse, family member, or signicant other. If you are filling this form out on behalf of someone else, please make sure that you are entering the PATIENT'S information.
Patient Name*

First NameLast Name
Date of Birth (DOB) *

MonthDayYear
Date
Gender*

MaleFemaleOther
Email*
Please confirm that this email is accurate and accessible as this is how Skippack Pharmacy will contact you regarding your interest in this program.
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business/Organization/Other Information

Please fill this section of the form out IF AND ONLY IF you are completing this form as a respresentative of a business/organization/crew/etc.
Name of Individual Completing Form*

First NameLast Name
Address of Individual Completing Form *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth of Individual Completing Form*

MonthDayYear
Date
Company/Organization/Other Name*
Company/Organization/Other Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Insurance Information

Please answer the following questions regarding your prescription insurance coverage. This form is HIPAA protected and the information collected will not be shared with any individual or organization outside of Skippack Pharmacy. The information below will solely be used to process the claim to ensure that you can receive this life-saving medication at no cost!
If you are filling this form out on behalf of a company/organization/office/etc. please complete the following questions using YOUR personal information.
Do you have insurance?*

YesNo
Last 4 Digits of SSN
The following information can be found on the front and/or back of your prescription (RX) insurance card.
RX BIN
RX PCN
RX GROUP
MEMBER ID / ID NUMBER
If able, please upload a picture/PDF of your insurance card. We may be able to process the claim without it, it may add additional time in processing and may require our team to contact you if necessary.

Browse Files
If you cannot upload a file, please continue and the pharmacy team will contact you if necessary. Cancelof
Naloxone (NARCAN) Education & Use History

Please complete the following questions so we can ensure that you are confident in your ability to use naloxone should you encounter someone experiencing an overdose from opioids. Skippack Pharmacy is a judgement-free zone -- we want to be able to provide the best care to our community and guarantee that its members are educated and able to use Naloxone to save the life of a loved one or stranger!
Is this medication for you? (i.e., are you currently taking any prescription opioid medications or exposed to non-prescription opioids?)*

YesNo, I'm requesting it in case someone other than myself experiences an overdose
Please attest that you understand this medication CANNOT be self-administered and a family/friend must be educated on how to use it in the event of an emergency.*

Yes, I understand that I cannot use Naloxone on myself and a family/friend must be educated on how to use it
Do you know how to administer Naloxone?*

YesNo
I have reviewed the above image on how to administer Naloxone*

Yes
If you would like to learn more about how to properly use/administer Naloxone, please click this link to watch a short video produced by the Skippack Team.
Pick-Up or Ship To You?

Once processed, you will be able to pick up your Naloxone kit from Skippack Pharmacy at any point during regular business hours. We are also offering for these kits to be shipped to you with a flat shipping & handling fee of $10.
How would you like to receive your Naloxone kit?*

I will pick it up in-person at Skippack PharmacyI would like my kit shipped to me with the $10 fee
If you selected to have your medication shipped to you, please fill out the following questions regarding MAILING information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number

Quick! Want to order for the whole family?

If you have any family members ON THE SAME INSURANCE that you entered before and want to order Naloxone kits for them as well, please list their FULL NAME & DATE OF BIRTH in the text box below.
Family Member(s) Full Name & Date of Birth
By signing below, I certify that I have completed this form to the best of my ability. By submitting this form, I am authorizing Skippack Pharmacy to bill my insurance to cover the cost of the Naloxone nasal spray kit. By signing this form, I acknowledge that, should there be a copay through my insurance, Skippack Pharmacy will cover any remaining copay and that I will not have any out-of-pocket costs for this medication. By signing this form, I acknowledge that any person health information (PHI) collected on this form will solely be used for completion of the prescription claims and will not be shared with any companies or organizations outside of Skippack Pharmacy and my insurance(s). *

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Naloxone (NARCAN) Interest Form

Let's learn a little more about you!

Patient Information

Business/Organization/Other Information

Insurance Information

Naloxone (NARCAN) Education & Use History

Pick-Up or Ship To You?

Payment Methods

Quick! Want to order for the whole family?