In response to the nationwide opioid epidemic, funding has been made available through the Florida Department of Health (DOH) for emergency opioid antagonists. The DOH has been appropriated $5,000,000 from the General Revenue Fund for the purchase of emergency opioid antagonists to be made available to emergency responders. DOH has established the HEROS Program for the purpose of acquiring emergency opioid antagonists for agencies that employ emergency responders. 

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* 1. Agency Information:

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* 2. Agency Head

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* 3. Agency Contact Information for HEROS Program

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* 4. Shipping Address

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* 5. Phone Number

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* 6. Primary County of Operation

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* 7. Is your agency a member of the Minnesota Multi-State Contracting Alliance for Pharmacy (MMCAP) ?

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* 8. Please provide your MMCAP account number if your agency is already a member.

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* 9. Federal Employee Identification Number

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* 10. Organizational Tax Status

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* 11. Organizational Type

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* 12. Percentage of Emergency Responders Trained to Administer Naloxone

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* 13. Total Number of Overdoses Responded to by the Applicant for the Previous Calendar Year

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* 14. Please indicate the total number of doses and for each type of Naloxone being requested:

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* 15. Narrative: (Please provide an explanation of the agency’s need to obtain Naloxone in 500 words or less)

OATH: “Under penalties of perjury, by submission to the Florida Department of Health, I declare that I have read the foregoing application and that the facts stated in it are true.” I understand that all I attest to in this application is subject to audit by the Department.

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