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Get Ds2076 Form
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How to fill out the Ds2076 Form online
Filling out the Ds2076 Form online is a crucial step for providers participating in the Opioid Overdose Prevention Program. This guide will help you navigate the form's sections, ensuring that all necessary information is accurately provided.
Follow the steps to successfully complete the Ds2076 Form online:
- Click the ‘Get Form’ button to access the Ds2076 Form and open it in your preferred editor.
- Begin by entering the program address and name in the designated fields.
- Under 'Authorized Provider Information', check all applicable boxes for your organization type such as Health Care Facility, Hospital, or Local Health Department.
- Input the NYS Operating Certificate Number and the NYS Permanent Facility Identification Number in the provided sections.
- Fill in the Program Director’s name, telephone number, fax, and email address in their respective fields.
- Indicate the License Type by checking either Physician, Physician Assistant, or Nurse Practitioner. Provide the NYS License Number if applicable.
- Describe your targeted population and outline your targeted responder outreach and recruitment strategy.
- List any affiliated prescribers by entering their names and corresponding license types, ensuring to provide the NYS License Numbers.
- Document the addresses of your Opioid Overdose Prevention Program sites, providing as many entries as necessary.
- Review the Opioid Overdose Prevention Program Attestation to ensure compliance with the program provisions.
- Gather signatures from both the Program Director and Clinical Director along with the respective dates.
- Once completed, save your changes, download the form, or print it as necessary for submission.
Complete your Ds2076 Form online today to contribute to opioid overdose prevention.
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