Voluntary Directory for PrEP (Truvada®)/PEP Providers

Question Title

In an effort to increase access to PrEP/PEP, the New York State Department of Health AIDS Institute (NYSDOH AI) is compiling a list of providers that prescribe PrEP/PEP for a voluntary directory.

Pre-Exposure Prophylaxis (PrEP): PrEP is the use of anti-HIV medications as a form of HIV prevention. Many clinics now offer PrEP to patients who have ongoing behavior that places them at high risk for HIV infection.

Post-Exposure Prophylaxis (PEP): PEP is the use of anti-HIV medications as a form of HIV prevention for individuals exposed to HIV.

Please complete your clinic/provider information as requested below.

Question Title

* 1. Clinic Information

Clinic Name

Address

Suite/Office Number

City/Town

Zip Code

Telephone Number

Question Title

* 2. Clinical Provider Contact Information

Clinical Provider's Name

Clinical Provider's 10-digit National Provider Identifier (NPI)

Email*

Phone Number

Question Title

* 3. Would you or your agency like to be included in this directory as a PrEP/PEP provider or as a contact that offers referral services?

PrEP/PEP Provider: for providers or medical facilities where PrEP prescriptions and clinical care can be obtained
**Please note; we often see miscommunication issues and find that providers will say that they prescribe PrEP/PEP but other staff members at their practice site/clinic are unaware of that or have no knowledge of PrEP/PEP at all. If you do prescribe PrEP/PEP, please ensure that all other staff members are aware of this and can direct patients accordingly.

PrEP Contact: for sites or community resource agencies that assists patients in finding PrEP clinical services but do not offer PrEP or PEP prescriptions

Other (please specify)

Question Title

* 4. Do you currently prescribe daily tenofovir/emtricitabine (Truvada®) for pre-exposure prophylaxis (PrEP) of HIV infection?

Yes

Question Title

* 5. Do you currently prescribe post-exposure prophylaxis (PEP) for possible HIV exposure?

Yes

Question Title

* 6. Any special directions for patients, when calling for PrEP/PEP?

Question Title

* 7. How many patients are you currently prescribing PrEP (Truvada®)?

This information provided will be compiled into a voluntary directory of PrEP/PEP providers, and published on our external site. This information will also be included in a national registry of PrEP prescribers so that we may work together with our bordering states to address regional gaps in access to PrEP.

Question Title

* 8. I understand that participation in this public directory is voluntary. I understand that by sharing the information above, I am agreeing to have this information be publically listed on the NYSDOH website and a national PrEP registry (with the exception of email address, email information is for NYSDOH internal use only). I understand that inclusion in this directory does not confer any endorsement by the NYSDOH nor does it establish NYSDOH credentialing or certification in a specialty.

I agree with the above statements.

Please provide information on other clinics/providers who, to your knowledge, are prescribing PrEP/PEP.

Question Title

* 9. Referral

Name

Phone Number

Email*

Name

Phone Number

Email*

Name

Phone Number

Email*

Name

Phone Number

Email*

Name

Phone Number

Email*

*Email: The email provided will not be made public or shared with anyone outside of NYSDOH. This is the email address we will use for contact. Please make sure it is listed correctly.