Get Mcsr:naloxone-nerve Agent Antidote - Epi Application ... - Mass.gov - Mass

The MCSR:Naloxone-Nerve Agent Antidote - Epi Application is a crucial form for municipalities and non-municipal public agencies in Massachusetts to authorize employees to administer life-saving medications. This guide provides clear, step-by-step instructions to assist you in completing the application accurately and efficiently.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to download the application form and access it in the preferred format.
2. Select the appropriate application type by marking the relevant box for 'New', 'Renewal', or 'Amended Information'.
3. In the applicant section, enter the full name of the municipality or public agency in the designated box.
4. Provide the complete street address of the applicant, ensuring not to use a P.O. Box without including a street address, as this may cause processing delays.
5. Indicate the telephone number of the applicant, including the area code, in the section provided.
6. Input the applicant's Federal Tax ID Number as required by Massachusetts law.
7. Enter the name of the authorized Medical Director who will be overseeing the use of the antidotes.
8. Read through the certification statement carefully, verifying all information provided is accurate and in compliance with relevant laws.
9. Have the Medical Director sign and date the form in the designated section to validate the application.
10. Attach the required documents including photocopies of the Medical Director’s Board of Registration in Medicine License and the Massachusetts Controlled Substances Registration.
11. Prepare the payment as instructed (if applicable) and ensure it is enclosed with the application.
12. Mail the completed application and attachments to the specified address, ensuring all documents are copies.
13. Once mailed, retain a copy of the submitted application for your records.

Start filling out your application online today to ensure timely authorization for your agency.