Table 1 Requested information on the electronic form for naloxone distribution
Requested Information | Response Options |
|---|---|
Full legal name | Free text field |
Phone number | Free text field |
Free text field | |
Date of birth | mm/dd/yyyy |
Do we have permission to bill your insurance for nasal naloxone? | ◦ Yes ◦ No |
You will not be charged for naloxone at the time, but this is permission to bill your insurance at the time of request. Note that you may still have a remaining copay to pay. | |
If you know your Prescription Insurance, please provide the following information: Bin: PCN: Group: ID/Subscriber #: | Free text field |
How would you like to pick-up your prescription? Mail Order is free, but make sure to include your address in the “Other” field. | • Outpatient Pharmacy @ 45 Francis St, Boston • Mail Order - please leaving mailing address in Other Field • Outpatient Pharmacy @ 20 Patriot Place, Foxborough • Outpatient Pharmacy @ 850 Boylston St, Chestnut Hill • Other - ______________ |
Additional comment | Free text field |