Healthcare Emergency Agreement

Healthcare Emergency Agreement

This Healthcare Emergency Agreement documents the patient's consent and instruction for emergency assessment, stabilization, treatment and transportation in the event the patient is unable to provide contemporaneous consent. Patient Name: Date of Birth:

Patient Contact Information

Gender: Male Female Other/Prefer not to say

Emergency Contact

Primary Care & Insurance

Medical History & Conditions

Is the patient currently under treatment for any condition that may affect emergency care? Yes No

Authorized Persons & Special Instructions

In the event the patient is incapacitated or otherwise unable to communicate, the following person(s) are authorized to receive medical information and make emergency decisions on the patient’s behalf:

Consent to Emergency Treatment and Transport

I, the undersigned patient or legal representative, authorize licensed medical personnel to perform all emergency medical care and procedures that are reasonably necessary to preserve life, prevent deterioration, or alleviate suffering, including but not limited to administration of medications, airway management, resuscitation, wound care, imaging, and emergency transport. This authorization includes consent for transport to an appropriate medical facility when deemed necessary by emergency personnel.

I acknowledge that emergency treatment may involve risks, including but not limited to allergic reaction, adverse medication effects, procedure-related complications, and transportation hazards. I understand that while providers will attempt to follow my stated medical history and advance directives, emergent circumstances may require immediate action to preserve life or health.

Authorization to Release and Obtain Medical Information

I authorize healthcare providers and facilities to disclose protected health information to the authorized persons listed above and to emergency personnel, to the extent necessary for their evaluation and treatment in an emergency. I also authorize providers to obtain relevant medical records from other healthcare entities to facilitate continuity of emergency care.

Limitations, Revocation and Duration

This Agreement remains in effect until the earlier of: (a) the Authorization Expiration Date identified below; (b) written revocation delivered to the provider; or (c) replacement by a subsequent valid directive. Revocation will not apply to actions taken prior to receipt of revocation.

HIPAA Acknowledgment

I acknowledge that I have been informed of my privacy rights under applicable law and that medical information may be shared with authorized persons and emergency personnel as necessary for treatment, payment, and healthcare operations in an emergency. I understand that this agreement constitutes an authorization under privacy law to disclose protected health information to the persons listed herein for the purposes described.

I acknowledge the following: I have read and understand this Healthcare Emergency Agreement or someone has read it to me and my questions were answered. I authorize emergency medical personnel to provide treatment and transport as described above.

Additional Declarations

Patient is a minor: Yes No

Patient currently incapacitated or lacks decision-making capacity: Yes No

By signing below, I certify under penalty of perjury and applicable law that the information provided is true and correct to the best of my knowledge, that I have authority to execute this Agreement (or I am signing as the patient's lawful guardian or representative), and that I voluntarily authorize the actions described herein.

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