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Iredell County Special Medical Needs Registry
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Page 1 of 4
CONDITIONS AND AUTHORIZATION TO RELEASE INFORMATION, INCLUDING PROTECTED HEALTH INFORMATION
Please read and initial each of the following:
(initial)
*
I hereby request that the information I have provided be listed in the Iredell County Special Medical Needs Registry and the North Carolina State Special Needs Registry. I understand that submitting the information to participate in the Iredell County Special Medical Needs Registry and the North Carolina State Special Needs Registry does not guarantee that I will be included in the Registries.
(initial)
*
I understand that my participation in this registry is voluntary and that all information that I provide will only be used for disasters and emergency planning and response purposes.
(initial)
*
I understand that at any time I may ask that my name be removed from the Registries by sending a written request to Iredell County Emergency Management and the NC Division of Emergency Management.
(initial)
*
I grant permission to emergency medical providers, transportation providers and other emergency responders to enter my residence in an emergency, to provide care and to disclose the information I have provided as needed to respond to my emergency needs. This is not intended to limit a responder’s ability to enter or respond to an emergency as allowable by law.
(initial)
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I understand that while registering this information may help emergency responders to know and understand my emergency needs, registration does not guarantee any particular emergency services or any level of emergency services during an emergency or disaster.
(initial)
*
I understand that I should call 911 if I am in an emergency, even though I have submitted information to the registry.
(initial)
*
I understand that I am responsible for making my own emergency preparations. This may include, but is not limited to, responsibility for establishing communication with family members or caregivers, and the provision of prescription medications, oxygen supplies, medical equipment, and special dietary items that I may require if I am evacuated from my home.
(initial)
*
I understand that I am responsible for all expenses associated with my emergency medical evaluation and care.
(initial)
*
I understand that I can bring my service animal to an emergency shelter, but I am responsible for the feeding and care of my animal.
(initial)
*
I understand that it is my responsibility to update the information I have provided at least once a year or when my information changes, whichever occurs first.
(initial)
*
I grant permission to medical providers, transportation agencies, and others as necessary to provide care and disclose any information necessary to respond to my needs.
(initial)
*
I understand that assistance will only be provided for the duration of the evacuation, emergency or disaster and that alternative arrangements should be made in advance in the event I am not able to return to my home.
(initial)
*
I understand that assistance will only be provided for the duration of the evacuation or emergency and that alternative arrangements should be made in advance in the event I am not able to return to my home.
(initial)
*
I understand that in the event I am not able to return to my home that I will be responsible for any additional transportation or hospital expenses.
(initial)
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I understand that upon order or recommendation to evacuate my residence, if I have requested transportation, I will receive advance notice, by phone, of the date and time to expect to be picked up for transport to a shelter.
(initial)
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If I decline transportation when a transporter arrives, I understand that I may not have another opportunity to obtain this service.
(initial)
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I understand that based on this information and the data I have provided; Iredell County Emergency Management and the NC Division of Emergency Management will determine if any emergency evacuation assistance will be provided.
(initial)
*
I understand that power is not guaranteed, due to unforeseen power fluctuations or power failures.
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Page 2 of 4
I understand that completing this form and including my information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry DOES NOT create a contract for services. Neither the entities or individuals that have created or maintained this registry or collected information for this registry, nor any entity or individual that may utilize the information contained in the registry including but not limited to, Iredell County Emergency Management, the Department of CCPS, Division of EM, Public Health authorities, human services agencies, emergency personnel and volunteers, warrant that assistance will be provided to you during an emergency or disaster.
I understand that participation in this registry is voluntary and this it is my duty and responsibility to update my information on this registry. By completing this registration form and including the information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry, I hereby confirm and attest that the information provided in this registration is correct and that should the information that I have provided change, I will promptly update the registry. By completing this registration form and including the information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry, I also hereby warrant that the information has been provided voluntarily and that if I have required assistance to complete this form that I have consented to the assistance provided. By completing this registration form and including the information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry, I also hereby waive any and all claims which relate to the collection, maintenance or use of the information I have supplied which may be asserted against the entities or individuals that have created or maintained this registry or collected information for this registry and any entity or individual that may utilize the information contained in the registry including but not limited to the Department of CCPS, Division of EM and emergency personnel and volunteers.
I understand that my participation in the Iredell County Special Medical Needs Registry and State Special Needs Registry is voluntary and that all information I provide, including any Protected Health Information, will be treated as confidential, but that under some limited circumstances the information may be released without my permission as allowable by federal or state law.
I further understand that the information I provide will only be released to the Department of CCPS, Division of EM, the County of Iredell and Public Health authorities, human services agencies, emergency responders, managers and planners, and those individuals who manage the Registry database.
I understand that the information that I have provided to the Registries will only be used in the following circumstances: to respond to disaster-related events; to respond to emergency needs; for evacuation and recovery efforts; and for disaster planning purposes.
I understand that under some limited circumstances the information may be released without my permission as allowable by federal or state law.
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION
I understand that I, or my personal representative, is entitled to receive a copy of the completed authorization form upon request. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke the authorization I must do so in writing and submit my written revocation to Iredell County Emergency Management. I understand that the revocation will not apply to information that has already been released. I also understand that once information is released to others, it may be re-disclosed to individuals or organizations not subject to state and federal privacy and confidentiality laws and may not be protected.
I have had full opportunity to read and consider the contents of this Authorization. I understand that, by signing this form, I am confirming my authorization that the Department of CCPS, Division of Emergency Management may disclose to the person(s)/organization(s) named in this form the information described in this form.
I certify that the above information is correct. I hereby authorize the Department of CCPS, Division of EM, to release, use or disclose this information to other emergency response or human service agencies or officials and to include this information in the State Special Needs Registry. I also give law enforcement permission to enter my home in case of an emergency. I understand that I have the right to revoke this permission by notifying Department of CCPS, Division of EM and asking that my name be removed from the special needs registry.
Electronic Signature
*
Enter your full name
Date
*
Date
If the person filling this out is not the patient please complete the following 2 lines:
Name:
Phone:
Relationship/Agency:
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Page 3 of 4
REQUIRED PERSONAL ENROLLMENT DATA
(One Person Per Form)
First Name
*
Last Name
*
Middle Name
Weight:
*
Sex:
*
Male
Female
Street Address:
*
City
State
Zip
Mailing Address:
(if different from above)
City
State
Zip
Primary Phone Number
*
Alternate Phone Number
Primary Language:
*
Name of Subdivision, Mobile Home Park, Apartment Building:
Living Situation
*
Living Alone
Living with Parents
Living with Spouse/Significant Other
Living with Children
Other (please explain)*
Enter explanation here:
*
Medical History (please check all that apply)
*
Allergies
Asthma/Emphysema (COPD)
Bedridden
Developmentally Disabled
G-Tube Feeder
Insulin Dependent
IV Medication
Medications*
Memory Impaired*
Mental Health Condition*
Ostomy Care
Oxygen Concentrator or Ventilator*
Physically Disabled
Portable Oxygen Machine
Refrigeration for Medication(s)
Seizures
Special Dietary Needs*
Speech Impaired
Suction Machine
Vision Impaired
Walker
Wheelchair Bound
Other*
An explanation field will appear for all answers marked with * .
Medications Explanation
*
Memory Impaired Explanation
*
Mental Health Condition Explanation
*
Oxygen Concentrator or Ventilator
*
Continuous
Intermittent
Special Dietary Needs Explanation
*
Other Explanation
*
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Page 4 of 4
Disaster Plan
If you require a special diet and must go to a shelter be prepared - pack and bring with you food you can eat and drink.
Choose One:
Stay with a friend/family member
Stay at home
Evacuate to shelter
Require transportation to a shelter*
Will bring a service animal or pet to the shelter
Other*
An explanation field will appear for all answers marked with * .
Require Transportation to a Shelter Explanation
*
Other Explanation
*
Emergency Contact Information
First Name
*
Last Name
*
Home Phone
*
Work Phone
Cell Phone
Medical Provider Information
Physician Name:
Phone
Pharmacy Name:
Phone
Home Health Agency
Phone
Medical Equipment Provider
Phone
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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