Naloxone Kits Request

ADHS, in coordination with AHCCCS, distributes naloxone to partners who are situated to distribute naloxone to individuals in the community who need it most.  If you are looking for one or two kits for personal use, please reach out to one of our distribution partner sites.  

Please be aware that completion of this form does not guarantee that your agency will receive naloxone.  Requests from partners will be followed up with a telephone call from our ADHS Program Manager to ensure statewide distribution focuses on targeted populations.  It may take up to 30 days to receive your naloxone, depending on the availability of ADHS’ monthly supply.

Please do not submit duplicate requests during this time.  When you receive your naloxone, please sign, date, and send a scanned copy of the packing slip to azopioid@azdhs.gov. SOMEONE MUST BE AVAILABLE DURING BUSINESS HOURS TO SIGN FOR THE PACKAGE.

Non-governmental, for-profit agencies generally do not meet requirements to receive ADHS naloxone unless the naloxone is being provided at no cost to at-risk individuals for harm reduction.  Naloxone is now available over the counter and can be purchased at most pharmacies.  Some insurances and Medicaid may cover naloxone with a prescription.  

Please provide the following information to request naloxone kits for your agency:  
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Email *
Naloxone Contact Name *
Naloxone Contact Phone Number *
Secondary Contact Name
Secondary Contact Phone Number
Secondary Contact Email
Agency Name (Please do not use acronyms) *
Agency Shipping Address (NOTE: We cannot ship to a residential address or a P.O. Box.  The address should be the physical address of the requesting agency. Someone must be available during business hours to sign for the package.) *
City *
County *
Zip Code *
Agency Type *
Agency Status: *
How are Kits being Distributed?  Check all that apply: *
Required
To what populations do you distribute kits?  Check all that apply: *
Required
Quantity Requested (2 doses per box) *
Nasal Naloxone Spray has two 4mg doses per kit/box.  Boxes should not be split as some overdose reversals require an additional dose.  Please only request what you can distribute within one month.  Depending on the number of kits requested, your order may be rounded to the nearest quantity of twelve (case size).  
If you are ordering for a specific event, when does the event take place?  (Please plan 30 days in advance whenever possible.)  
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If you are ordering for an event, please describe the event and let us know who is sponsoring/organizing the event.  
Anything else we need to know?  Please notate here if you have upcoming closure dates that would prevent accepting a delivery during regular weekday business hours.  
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