Sarpy County E911 Medical Alert Information
(Please Print)
NAME: ___________________________________
ADDRESS: _______________________________
CITY: ____________________________________
PHONE NUMBER: ___________ BIRTHDATE: _______
Please place your initials in the space provided for all
conditions which apply.
| _____ USE A CANE | _____ ASTHMA |
| _____ USE A WHEELCHAIR | _____ BREATHING PROBLEMS |
| _____ USE A WALKER | _____ USING OXYGEN |
| _____ BLIND | _____ DIABETIC |
| _____ DIFFICULTY SEEING | _____ DEAF |
| _____ READ LIPS | _____ HARD OF HEARING |
| _____ DIFFICULTY SPEAKING | _____ SEIZURES |
| _____ UNABLE TO SPEAK | _____ HIGH BLOOD PRESSURE |
| _____ HEART CONDITION | _____ PETS IN RESIDENCE |
|
_____ PSYCHIATRIC/EMOTIONAL PROBLEMS |
|
| _____ ALLERGIES TO ANY MEDICATIONS: | (PLEASE LIST) |
| _______________________________ | ___________________________ |
| _______________________________ | ___________________________ |
| _____ OTHER: (PLEASE LIST) | |
| _______________________________ | |
| _______________________________ | |
| _______________________________ |
_____ I HEREBY AUTHORIZE ENTRANCE 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
IN CASE OF AN EMERGENCY, PLEASE NOTIFY:
NAME: ________________________________________
RELATION: _____________________________________
HOME PHONE NUMBER: __________________________
WORK PHONE NUMBER: __________________________
PLEASE SIGN AND DATE BELOW:
SIGNATURE: __________________________ 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.