Sarpy
County E911 Medical Alert Information
(Please Print)
Name:__________________________________________________________
Phone:_________________________________________________________
Address: _______________________________________________________
Birthdate: _________________________________________
Please place your initials next to all conditions which apply.
|
COMMUNICATIONS ISSUES
|
MEDICAL CONDITIONS
|
| _____ Sight Issues | _____ Heart Conditions |
| _____ Blind | _____ Breathing Problems |
| _____ Deaf | _____ Asthma |
| _____ TDD Machine in Residence | _____ On Oxygen |
| _____ Able to Read Lips | _____ Diabetic |
| _____ Hard of Hearing | _____ Seizures |
| _____ Difficulty Speaking | _____ High Blood Pressure |
| _____ Unable to Speak | _____ Allergic to Medication (explain below) |
|
MENTAL STATUS |
OTHER
|
| _____ Behavior Issues | _____ Living Will |
| _____ Emotional Issues | _____ DNR (Do Not Resuscitate) Order |
| _____ Psychiatric Issues | _____ Advanced Directives |
| _____ Dementia (explain below) | _____ Hospice |
|
_____ Emergency Response System (ex: Lifeline) |
|
| _____ Pets in Residence | |
|
Remarks Regarding Any Conditions: ________________________________________________ ________________________________________________________________________________ |
|
Medications Taken: _______________________________________________________________ ________________________________________________________________________________ |
|
| Yes No I hereby authorize forced entry into my residence by any law enforcement and/or fire and rescue personnel if it is believed that I am in need of assistance and am incapacitated. If No, is there a key available or a combination to enter? ______________ |
|
| Yes No Do you need electricity for any medical equipment? | |
| Yes No I would like assistance from other agencies (ex: ENOA, HHS, etc)? | |
| In case of emergency, please contact: Name: _________________________________________ | |
| Phone Number: ________________________ Relation: ________________________________ | |
| Alternate contact information: Name: ________________________________________________ | |
| Phone Number: ________________________ Relation: ________________________________ | |
| Signature: _______________________ Relation: _____________________ Date: _________ | |
Acknowledgment of Receipt of Notice of Privacy Practices
By signing this form, you acknowledge that Sarpy County has given you a copy of its Notice of Privacy Practices, which explains how your health information will be handled in various situations. We must try to have you sign this form on your first date of service with us after April 14, 2003. This includes the situation where your first date of service occurred electronically. WE ARE REQUIRED BY FEDERAL LAW TO GIVE YOU THIS INFORMATION AND FOLLOW THESE PROCEDURES.
If your first date of service was due to an emergency, we must try to give you this notice and get your signature acknowledging receipt of this notice as soon as we can after the emergency.
Check all that are true:
____ I have received Sarpy County's Notice of Privacy Practices.
____ Sarpy County has given me
the chance to discuss my concerns and
questions about
the privacy of my health information.
____________________________________________________________
Signature of Patient/Client/Legal Guardian/Personal Representative/ Subject of
Records
_______________________
Date
Sarpy County Staff should complete the following if Acknowledgment Form is not signed:
1. Does the patient have a copy of the Notice Form? ____ yes ____ no
2. Please explain why the
patient was unable to sign an Acknowledgment
Form and Sarpy County's
efforts in trying to obtain the patient's signature:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please print off this form and then complete. A separate form should be completed for each individual member of the residence to whom conditions apply (i.e. one for husband, one for wife).
This information will be kept on file in the Sarpy County 911 center and will NOT be released to anyone without your consent. Your signature certifies that you have the conditions marked and/or authorizes entry into your residence in case of an emergency.