Healthcare Contingency Planning Procedures

Healthcare Contingency Planning Procedures

1. Purpose and Scope

These Contingency Planning Procedures set forth mandatory operational protocols, patient-specific contingencies, notification and transfer authorities, and privacy provisions to be implemented by the facility during declared or emerging emergencies that materially disrupt normal operations. These procedures apply to all patients receiving care at the facility and to authorized representatives acting on a patient’s behalf.

2. Patient Identification and Contact Information

3. Insurance and Responsible Party

4. Medical History and Critical Needs

Special assistance required during an evacuation (select all that apply):

5. Procedure Activation and Transfer Authority

Activation Criteria: The facility will activate contingency procedures upon declaration of an emergency by facility leadership, local or state public health authority, or when events materially compromise safe continuity of care. Activation may include relocation, cohorting, suspension of non-essential services, and transfer to alternate care sites.

Patient Authorization for Transfer: I authorize the facility and its agents to transfer me to an alternate care site, receiving facility, or temporary shelter if required by the contingency response. I understand transfers entail risks, including treatment interruptions, transportation risks, and potential changes in provider and available services.

6. Release of Health Information for Contingency Response

Authorization to Disclose: To facilitate continuity of care during activation, I authorize disclosure of my medical information, including medical history, medication list, allergies, and advance directives, to receiving providers, public health authorities, emergency response personnel, and alternate care sites to the extent necessary for treatment, transport, and public health response.

This authorization is effective upon activation of contingency procedures and expires on:

7. Communication and Notification Protocols

Notification hierarchy: The facility will attempt to notify the emergency contact listed herein and will provide status updates regarding transfer, care location, and estimated return of normal operations as soon as practicable. Patient preferences for method of contact should be indicated below.

8. Resource Allocation, Medications, and Durable Medical Equipment

The facility will prioritize resources to preserve life and prevent serious harm. Where resource constraints require triage decisions, allocation will follow established ethical and legal guidelines. Patients with critical ongoing supplies or equipment should list items below to support planning and continuity.

9. Infection Control and Isolation Considerations

During infectious disease events, cohorting and isolation protocols may limit direct visitation and alter transfer destinations. I acknowledge that infection control measures may be applied to protect public health and that such measures may affect location and modality of care.

10. Authority, Responsibilities, and Withdrawal of Consent

Facility authority: Facility leadership, or their designee, is authorized to implement contingency procedures and make transfer or cohorting decisions consistent with these procedures and applicable law. Patient or authorized representative may withdraw consent for non-emergency transfers at any time by providing written notice; however, the facility retains the right to take necessary actions if immediate transfer or intervention is required to prevent serious harm.

11. Documentation and Recordkeeping

All activations, decisions, notifications, and transfers made under these procedures will be documented in the patient's medical record, including the rationale, receiving facility/provider, time of transfer, and any patient or representative communications.

12. HIPAA / Privacy Notice Acknowledgment

I acknowledge that my health information may be disclosed as necessary for treatment, payment, or health care operations during contingency activation and as authorized above. Such disclosures will be limited to the minimum necessary to accomplish the contingency response objectives, consistent with applicable privacy rules.

13. Training, Drills, and Review

The facility will conduct periodic training and drills to validate the effectiveness of contingency planning. Patient-specific contingencies will be reviewed at admission and at clinically significant intervals to ensure plans remain current.

14. Additional Notes

15. Patient Acknowledgment and Authorization

By signing below, I certify that I have read and understand these Contingency Planning Procedures, that the information I have provided is accurate to the best of my knowledge, that I authorize disclosure and transfer as set forth above during contingencies, and that I understand my rights to withdraw consent except as limited by emergency circumstances.

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