Program Details

Program Name *

First Name *

Last Name *

Email *

Phone *

Alternate Contact Name (optional)

Alternate Contact Email (optional)

Alternate Phone (optional)

Please let us know where your program operates. If approved as a member of RAFTP you will have the ability to set up shipping and billing addresses in your customer profile.

Address Line 1 *

Address Line 2

City *

State *

Zip *

Country *

RA/FTP works with low/no-barrier programs who are distributing naloxone free of charge primarily to people who use drugs and their social networks.

Program Description *

Please let us know what type of program you operate: *

Syringe Services Program (SSP)
Mutual Aid/Outreach
Entity purchasing on behalf of SSPs or other harm reduction programs
Other

Please describe *

Which of the following options describe your organizational structure: *

501(c)(3) nonprofit
Other nongovernmental nonprofit (using a fiscal sponsor, 501(c)(3) status pending, etc)
Governmental agency (health department, university)
For-profit entity (*if you are a for-profit entity such as a methadone provider, we will follow-up for more information)
Other

Please describe *

Please tell us a few sentences about your naloxone distribution activities: *

Funding and naloxone needs:

Please answer the following questions to the best of your ability to help determine how we can best support your work.

If you could meet your community's needs without operating in resource scarcity-mode, how many vials of injectable naloxone would you need per year?

*Remedy Alliance/For the People is a source of large volume supply for distribution to PWUD. If you are seeking smaller volumes (e.g. less than 1000 vials per year) we suggest working in collaboration with another program in your area.

Target volume distributed per year(# of vials) *

Funding and Resources *

Yes, we currently have resources for naloxone
Partially, we have some funding but not enough for the volume we need
We receive no funds for naloxone

Naloxone distribution under standing order or prescription:

Federal law requires that naloxone be distributed only via prescription (which can be a standing order). *

We certify that our organization is legally permitted to receive and distribute naloxone in our state.
We do not currently have a prescriber or our state does not have a standing order under which we can operate. Please contact us for follow-up and technical assistance.

Sales Tax Exemption

If you are exempt from sales tax, please upload your local sales and use tax exemption certificate issued by your state.

This is not your 501(c)(3) letter of determination. We do not need your 501c3 documentation or fiscal sponsorship information. If you do not have sales tax exemption, please leave this blank.

Upload your documentation

jpg, jpeg, png, and pdf are acepted file types

Hidden

How did you hear about us? *

We were a previous Buyers Club member
We were referred by a previous Buyers Club member
Web search or social media
Other

Thank you for your application to Remedy Alliance/For the People!

Please allow a few days for us to review your application and get back to you. If you meet our requirements for accessing naloxone through our program, we'll send you an account activation email. At that time, you'll be able to set up a login and password and begin placing orders for naloxone.

We respond to everyone who applies, so if you do not see a response within a few days **PLEASE CHECK YOUR SPAM FOLDER.**

If we have questions about your application we will contact you via email or the phone number you provided.

Our eligibility requirements:

1. Must be purchasing/receiving naloxone for distribution to community members at no cost to the recipient.

2. May not resell naloxone, bill insurance, or charge a fee to end-users for receipt of naloxone.

3. Must commit to providing low-threshold/low or no-barrier distribution to people at risk of opioid overdose or likely to witness an opioid overdose.

4. Must commit to distributing the majority of naloxone you receive via RA/FTP directly to people who use drugs and structuring distribution around the goal of saturating communities of people who use drugs with naloxone on an ongoing basis, including supporting robust peer distribution.

The following groups are ineligible:

1. Individuals wishing to obtain a personal supply of naloxone

2. First responder organizations like law enforcement, emergency medical services and fire departments who intend to use the product for administration during the course of their professional duties

3. Hospitals, pharmacies and other medical/health care entities who are purchasing naloxone for in-hospital use, co-prescription, or pharmacy-based dispensing.

If you have questions, please contact us at info@remedyallilanceftp.org

Thank you!

Maya and Eliza (RA/FTP)

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