Healthcare Emergency Protocol

HEALTHCARE EMERGENCY PROTOCOL

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Emergency Contacts

Relationship:    Phone:

Insurance & Identification

Policy Number:    Group Number:

Medical History & Current Status

Latex allergy    History of anaphylaxis    EpiPen available

Mobility assistance required: If selected, describe:

Advance Directives & Decision Makers

Do-Not-Resuscitate (DNR) order in effect:

Proxy Phone:    Advance directive on file:

Emergency Treatment Authorization & Protocol

Effective Date:    Expiration Date (if any):

I, the undersigned Patient Name above, authorize licensed medical personnel, including emergency medical technicians, paramedics, physicians and hospital staff, to provide emergency assessment, diagnostic procedures, life‑saving treatment and transport as necessary when I am incapacitated or unable to provide contemporaneous informed consent. This authorization includes administration of medications, airway management, cardiopulmonary resuscitation, defibrillation, immobilization, and other emergency procedures that, in the judgment of the treating clinicians, are necessary to preserve life or prevent serious harm.

I authorize release of relevant protected health information to emergency responders, treating hospitals and other health care providers for the purpose of evaluation and treatment during an emergency. Such disclosure may include medication lists, allergies, advance directives status and immunization information. This authorization is limited to information necessary for emergency care and does not authorize disclosure for unrelated purposes.

If I have expressed a preference for a specific facility or treating clinician below, I understand that in certain circumstances (including immediate life threat or resource unavailability) transport to the nearest appropriate facility may be required.

Special Considerations & Instructions

Use of automatic external defibrillator (AED) permitted:

HIPAA & Privacy Acknowledgment

By signing below, I acknowledge that I have been informed that, in an emergency, clinicians may need to access or disclose protected health information to provide necessary care. I authorize such disclosures to the extent required for treatment, transport, and coordination of emergency services. This authorization is limited in scope to emergency evaluation and treatment as described in this protocol.

Right to Revoke: I understand I may revoke this authorization at any time by providing written notice to my primary health provider or the facility maintaining this protocol, except to the extent that action has already been taken in reliance on this authorization. Revocation does not apply to disclosures made under this authorization prior to receipt of the revocation.

Certification

I certify that the information provided in this Healthcare Emergency Protocol is accurate to the best of my knowledge. I understand that this protocol is intended to guide emergency responders and treating clinicians and does not replace clinical judgment. I accept responsibility to update this protocol if my medical condition, medications, or emergency contacts change.

Sign Now