Healthcare Contingency Plan

HEALTHCARE CONTINGENCY PLAN

Purpose: This Healthcare Contingency Plan documents procedures, responsibilities, and patient-specific instructions to ensure continuity of safe, medically necessary care for the patient named below during an emergency, disaster, or temporary disruption of normal services. Facility Name: Plan ID: Date Developed:

1. Patient Information

Date of Birth: Gender:

Primary Phone: Alternate Phone:

2. Emergency Contact

Relationship: Phone:

3. Insurance Information

Policy Number: Group Number:

4. Medical History and Functional Needs

Functional needs (check all that apply):
Mobility assistance (wheelchair/walker)   Cognitive support   Sensory assistance (visual/hearing)   Medical equipment dependency (e.g., oxygen, ventilator)

5. Care Prioritization and Alternate Care Sites

Primary Care Provider: Phone:

6. Activation Criteria

This plan may be activated when any of the following conditions apply (check all that apply):
Natural disaster affecting facility operations   Utilities or infrastructure failure   Infectious disease outbreak   Mass casualty or surge event

7. Communication Plan

8. Medical Records, Privacy, and Information Sharing

To ensure continuity of care, limited protected health information may be disclosed to alternate care sites, transport providers, and clinical staff as required by this plan. Patient hereby authorizes such disclosures consistent with applicable privacy practices and for the purposes described in this plan.

Patient Acknowledgment: I acknowledge that I have read and understand the information-sharing provisions above and consent to disclosures necessary to carry out this contingency plan.

9. Supplies, Pharmaceuticals, and Logistics

10. Recovery and Deactivation

The facility will document deactivation of contingency operations and the steps required to resume normal operations. Recovery actions include clinical reassessment, reconciliation of medications and equipment, and notification of the patient and emergency contacts.

11. Training, Exercises, and Plan Review

12. Certification and Agreement

By signing below, Patient Name: authorizes the named facility and its authorized agents to implement the contingency measures documented in this plan for the purpose of preserving health and safety during the activation period. Patient understands that this authorization permits sharing of protected health information with receiving facilities, transport providers, and clinical personnel as necessary to effectuate continuity of care.

Patient understands the right to revoke this authorization in writing at any time except to the extent that the facility has already taken action in reliance on the authorization. Patient also understands that refusal to sign may limit the facility's ability to provide certain contingency services and that no specific guarantee of outcome is made by the facility.

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