Healthcare Emergency Action Plan

HEALTHCARE EMERGENCY ACTION PLAN

Purpose: This Emergency Action Plan (EAP) documents the patient’s baseline status, known medical conditions, specific triggers, medication and intervention instructions, and emergency response procedures to be followed by caregivers, staff, and emergency responders. This Plan is intended to authorize and guide prompt treatment in the event of an acute medical emergency and to provide legally relevant information to medical personnel.

Patient Information

Patient Name:   DOB:   Gender:

Insurance / Responsible Party

Medical History & Baseline

Triggers, Signs, and Typical Presentation

Emergency Response Procedures

Immediate Steps (order of priority): 1) ; 2) ; 3) .

I authorize trained staff or authorized caregivers to administer the medications listed above in accordance with this Plan.

Emergency Notification & Transport

Call Emergency Services (911 or local equivalent) for any life‑threatening event. After emergency services are contacted, notify listed contacts: Primary Contact: . Secondary Contact: .

Ambulance transport permitted     Private vehicle transport preferred (non‑life‑threatening only)     No transport without prior consent from listed contact

Communication & Follow‑Up

Authorization, Consent, and Legal Notices

Authorization: I authorize the persons named in this Plan and medical personnel to provide and administer emergency care and medications as described. I grant permission for the exchange of relevant medical information among caregivers, health care providers, emergency responders, and facility staff for purposes of treatment and coordination of care.

HIPAA Acknowledgment: By signing below I acknowledge that information contained in this Plan may be disclosed to emergency responders and treating clinicians as permitted under applicable privacy laws for purposes of medical treatment and emergency care.

Right to Revoke or Amend: I understand that I may revoke or modify this Emergency Action Plan at any time by providing written notice to the responsible facility or primary caregiver. Revocation will not apply to actions already taken in reliance on this Plan prior to receipt of the revocation.

Liability and Good Faith Reliance: I authorize caregivers and responders to act in good faith reliance on the information and consents contained in this Plan. Where emergency treatment is provided in accordance with this Plan, I release providers and facility staff from liability for outcomes arising from compliance with these written instructions, except in the case of willful misconduct or gross negligence.

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