Get State Of Connecticut Naloxone Program Counseling ...

Completing the State Of Connecticut Naloxone Program Counseling documentation form is essential for pharmacists after providing naloxone administration counseling. This guide offers a step-by-step breakdown to ensure that all required information is submitted accurately and efficiently.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editing tool.
2. Begin by filling in the 'Date of Patient Administration Training' in the provided space, ensuring that you include the actual training date.
3. Next, enter your name as the pharmacist overseeing the naloxone provision.
4. If you are refilling a prescription, fill out the 'RX Number' and 'Pharmacy Zip Code'.
5. Select the options for question 1 by marking the appropriate box to indicate who prescribed the naloxone.
6. For question 2, specify whether this is an initial prescription or a refill. If it is a refill, indicate the fill number.
7. Identify the recipient of the prescription in question 3 by checking the relevant option.
8. For question 4, indicate which naloxone dosage form was dispensed by selecting the appropriate box.
9. Question 5 pertains to billing; indicate whether the prescription was reimbursed and specify the payment method.
10. In question 6, choose the treatment resource list provided to the patient from the options available.
11. Complete question 7 by indicating whether a referral to a substance abuse service was provided.
12. If applicable, answer questions 8 to 12 regarding previous naloxone usage and its outcomes, ensuring to check the relevant boxes.
13. Review the form thoroughly for accuracy. Once complete, save your changes, and use the available options to download, print, or share the form as necessary.

Complete your documentation online today with confidence!