Registration

Certification Name	Certification Date
Cert Name	Cert Date

PrEP & PEP

Indicates a required field

Clinical Provider's 10-digit National Provider Identifier (NPI):

Do you prescribe daily tenofovir/emtricitabine (Truvada ®) for pre-exposure prophylaxis (PrEP) of HIV infection?

Yes No

Number of patients currently being prescribed PrEP:

Do you have PEP medication on-site to provide emergency HIV exposure treatment?

Yes No

Can members of the public access PEP follow-up care at your site?

Yes No

Buprenorphine

Indicates a required field

Do you currently prescribe buprenorphine to treat patients with opioid use disorder (OUD)?

Yes No

Do you accept Medicaid and/or insurance coverage to prescribe buprenorphine?

Yes No

In what clinical setting(s) do you prescribe buprenorphine [please select all that apply]?

Do you have a DEA License?

Yes No

Please enter your DEA license number:

HIV

Indicates a required field

Confirm Professional Degree type for HIV care. All registrants must have at least one of the following degrees:

Confirm Professional Credentials for HIV care:

The following questions are for internal NYSDOH use only. Your answers will not be made public.

HCV

Indicates a required field

Individual Provider Attestation:

Do you have experience with management AND treatment of at least 10 patients with HCV infection within the past 12 months OR Management and treatment of 10 patients with HCV infection in partnership (defined as consultation, preceptorship, or via telemedicine) with an experienced HCV provider who meets the above criteria ?

Yes No

STI

Indicates a required field

Does this facility accept Medicaid Insurance?

Yes No

Which of the following do you provide care for?

Does your facility prescribe Expedited Partner Therapy (EPT) for the partners of patients diagnosed with Chlamydia?

Yes No

PEP Hotline Network

Indicates a required field

PEP Medication:

Stock PEP Medication Routinely:

Yes No

Naloxone Pharmacy

Indicates a required field

Have you completed the free CPE training?

Yes No