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 *

Remedy Alliance can only ship to US states and Territories.

Remedy Alliance/For the People works with low/no-barrier programs who are distributing naloxone and other supplies free of charge primarily to people who use drugs and their social networks.

RAFTP is primarily a naloxone access program but we also offer access to other medicines and supplies. Please let us know what products you're interested in:

Generic injectable naloxone (0.4mg/1ml vials)
Assembled injectable naloxone kits
RiVive® 3mg nasal spray
Julie®Emergency Contraceptive

Brief program description: *

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

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

Please describe *

Do you (or the group(s) you are ordering on behalf of) distribute other safer drug use supplies? Check all that apply: *

Syringes
Safer smoking supplies (pipes, etc.)
Test strips
We do not distribute any of these supplies

Which of the following options describe your organizational structure: *

Tax-exempt 501(c)(3) nonprofit
Unincorporated group, using a fiscal sponsor or 501(c)(3) status pending
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 describe *

Please tell us a few sentences about your harm reduction supply distribution activities: *

Total budget (per year): *

Please check all that apply to your program:

Black, Indigenous, Latine(x), API, POC-led
LGBTQIA2S+ led
Led by people with lived and/or living experience of drug use and/or sex work
Operating in environment that is politically/legally hostile to harm reduction services
Operating in environment with few other harm reduction resources

Funding and supply 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 doses of naloxone would you need per year? (# of doses) *

*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 doses of naloxone per year) we suggest working in collaboration with another program in your area.

Naloxone funding: *

We are funded to purchase the volume of naloxone we need
We have some funding to purchase naloxone but not enough for the volume we need
We receive no funds to purchase naloxone

Access to naloxone from other sources: *

We receive an adequate amount of naloxone from another source (i.e. state, city our county naloxone distribution program)
We receive some naloxone from other source(s) but it is not enough to meet our needs
We receive no naloxone from another source
Not applicable (please check this if you are a state/county/city/institutional purchaser)

Naloxone distribution under standing order or prescription:

Federal regulation requires that Rx 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 standing order (If this is your answer, please still submit your application).

Sales Tax Exemption

Prescription medication (injectable naloxone) is not subject to sales tax. We offer emergency contraceptives for free so this product is also not subject to sales tax.

RiVive is an OTC medication, so it IS subject to sales tax. If you are *purchasing* RiVive, 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 or you are not purchasing RiVive, please skip to the next question.

Upload your documentation

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How did you hear about us? *

We were referred by another Remedy Alliance member
Web search or social media
Other (please describe)

Please describe

Please review and confirm that you commit to Remedy Alliance's eligibility requirements:

We commit to providing low-threshold/low or no-barrier supply distribution including supporting robust peer distribution. *

We are purchasing/requesting supplies for distribution to community members at no cost to the recipient. We will not resell supplies, bill insurance, or charge a fee to end-users for receipt of supplies. *

We commit to distributing the majority of naloxone (and any other supplies) received from Remedy Alliance directly to people who use drugs and their social networks. *

We confirm that we are not supplying law enforcement, emergency medical services or fire departments who intend to use the product for administration during the course of their professional duties, hospitals, pharmacies or other medical/health care entities for in-hospital use, co-prescription, or pharmacy-based dispensing. *

Testing Form