I am requesting a hospital account to directly order naloxone (Narcan nasal spray) through IDHS/SUPR. Hospitals that receive Narcan through this program are required to comply with the grant requirement to submit data related to the distribution of naloxone through a mechanism developed by IDHS/SUPR. Reporting will be reflected in the portal. I will be sent information on how to submit the data upon submission of this form.

IMPORTANT: Your submission is not complete, and will not be approved, until you fill out this form completely including signing and dating on the final page.