NALOXONE INTEREST FORM

Naloxone (NARCAN) Interest Form

Complete this quick HIPAA-secure form to request your free Naloxone (NARCAN) kit through Skippack Pharmacy. Whether for yourself, a loved one, your workplace, or your community, our team will help make sure you have access to this life-saving medication at no cost.
Thanks to the PACE Assistance Program, many patients can receive Naloxone through their insurance with a $0 copay.

If insurance does not cover it, or if you are uninsured, Skippack Pharmacy will still make sure you receive Naloxone at no cost because access to life-saving medication should never be a barrier.
Let's learn a little more about you!

We welcome all patients, families, workplaces, and community organizations interested in learning more about Naloxone and its life-saving benefits.This HIPAA-secure form collects only the information needed to help process your request and ensure you can receive Naloxone at no cost whenever possible.
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
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
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.
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!
YesNo, I'm requesting it in case someone other than myself experiences an overdose
Yes, I understand that I cannot use Naloxone on myself and a family/friend must be educated on how to use it
YesNo
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.
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?