Healthcare Outing Protocol

HEALTHCARE OUTING PROTOCOL

Patient Information

Insurance Information

Medical History & Current Status

Outing Details

Medication & Medical Device Administration

During the outing, authorized staff may administer prescription medications, provide medical device support, and perform necessary first aid in accordance with the patient's documented orders. Administration of any medication not listed below requires separate written authorization.

Risk Acknowledgment & Release

I, the undersigned, acknowledge that participation in off-site outings involves inherent risks, including but not limited to changes in medical condition, environmental hazards, transportation incidents, and interruption of facility-based supports. I understand that supervising staff will take reasonable precautions but cannot eliminate all risks. I hereby authorize the listed staff to provide necessary care and to seek emergency medical treatment if required. I understand that I remain responsible for informing staff of any change in condition prior to departure.

I further authorize release of protected health information to entities involved in the outing as necessary for safe transport and treatment. This release is limited to the minimum information necessary to provide care during the outing.

By signing below I consent to participation in the outing as described, authorize medication and device support as indicated, and acknowledge I may withdraw consent at any time prior to departure. I understand that withdrawal of consent may result in cancellation of the outing.

Emergency Plan & Notifications

If emergency medical treatment or transport is required, staff will make reasonable efforts to notify the emergency contact listed above and the facility's on-call clinician. The costs of emergency transport and treatment are the responsibility of the patient or their insurer.

Screening & Infection Control

The patient must not participate in an outing if presenting signs of acute illness communicable to others. Staff will perform a pre-departure screening for symptoms. If the patient becomes ill before or during an outing, staff may terminate participation to protect the patient and others.

I acknowledge that certain transport or venue requirements (such as mask use or distancing) may apply and that I will comply with reasonable infection-control measures imposed for safety.

Authorization Period & Limitations

This authorization is effective for the outing(s) specified above and for any reasonable return transit. This authorization expires on: . Any changes to outing details or medication orders require prior written modification of this protocol.

Consent Options

Please indicate consent choices by checking the applicable boxes below:

I consent to participation in the outing under the terms set forth in this protocol.
I authorize facility staff to administer listed medications during the outing as ordered.
I authorize emergency transport if medically necessary and consent to release of necessary information to treating providers.
I authorize the release of limited protected health information to transport and receiving providers as necessary for care.

Attestation

I certify under penalty of perjury that the information provided on this protocol is true and complete to the best of my knowledge. I understand that falsification of medical information may place me at increased risk during an outing and may result in revocation of outing privileges.

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