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NEW YORK STATE DEPARTMENT OF HEALTH AIDS Institute Opioid Overdose Prevention Program Registration Program Address Program Name Authorized Provider Information: (Check all that apply) Health Care.

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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:

  1. Click the ‘Get Form’ button to access the Ds2076 Form and open it in your preferred editor.
  2. Begin by entering the program address and name in the designated fields.
  3. Under 'Authorized Provider Information', check all applicable boxes for your organization type such as Health Care Facility, Hospital, or Local Health Department.
  4. Input the NYS Operating Certificate Number and the NYS Permanent Facility Identification Number in the provided sections.
  5. Fill in the Program Director’s name, telephone number, fax, and email address in their respective fields.
  6. Indicate the License Type by checking either Physician, Physician Assistant, or Nurse Practitioner. Provide the NYS License Number if applicable.
  7. Describe your targeted population and outline your targeted responder outreach and recruitment strategy.
  8. List any affiliated prescribers by entering their names and corresponding license types, ensuring to provide the NYS License Numbers.
  9. Document the addresses of your Opioid Overdose Prevention Program sites, providing as many entries as necessary.
  10. Review the Opioid Overdose Prevention Program Attestation to ensure compliance with the program provisions.
  11. Gather signatures from both the Program Director and Clinical Director along with the respective dates.
  12. 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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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232