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Iredell County Special Medical Needs Registry

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    1. CONDITIONS AND AUTHORIZATION TO RELEASE INFORMATION, INCLUDING PROTECTED HEALTH INFORMATION

    2. Please read and initial each of the following:

    3. I hereby request that the information I have provided be listed in the Iredell County Special Medical Needs Registry and the North Carolina State Special Needs Registry. I understand that submitting the information to participate in the Iredell County Special Medical Needs Registry and the North Carolina State Special Needs Registry does not guarantee that I will be included in the Registries.

    4. I understand that my participation in this registry is voluntary and that all information that I provide will only be used for disasters and emergency planning and response purposes.

    5. I understand that at any time I may ask that my name be removed from the Registries by sending a written request to Iredell County Emergency Management and the NC Division of Emergency Management.

    6. I grant permission to emergency medical providers, transportation providers and other emergency responders to enter my residence in an emergency, to provide care and to disclose the information I have provided as needed to respond to my emergency needs. This is not intended to limit a responder’s ability to enter or respond to an emergency as allowable by law.

    7. I understand that while registering this information may help emergency responders to know and understand my emergency needs, registration does not guarantee any particular emergency services or any level of emergency services during an emergency or disaster.

    8. I understand that I should call 911 if I am in an emergency, even though I have submitted information to the registry.

    9. I understand that I am responsible for making my own emergency preparations. This may include, but is not limited to, responsibility for establishing communication with family members or caregivers, and the provision of prescription medications, oxygen supplies, medical equipment, and special dietary items that I may require if I am evacuated from my home.

    10. I understand that I am responsible for all expenses associated with my emergency medical evaluation and care.

    11. I understand that I can bring my service animal to an emergency shelter, but I am responsible for the feeding and care of my animal.

    12. I understand that it is my responsibility to update the information I have provided at least once a year or when my information changes, whichever occurs first.

    13. I grant permission to medical providers, transportation agencies, and others as necessary to provide care and disclose any information necessary to respond to my needs.

    14. I understand that assistance will only be provided for the duration of the evacuation, emergency or disaster and that alternative arrangements should be made in advance in the event I am not able to return to my home.

    15. I understand that assistance will only be provided for the duration of the evacuation or emergency and that alternative arrangements should be made in advance in the event I am not able to return to my home.

    16. I understand that in the event I am not able to return to my home that I will be responsible for any additional transportation or hospital expenses.

    17. I understand that upon order or recommendation to evacuate my residence, if I have requested transportation, I will receive advance notice, by phone, of the date and time to expect to be picked up for transport to a shelter.

    18. If I decline transportation when a transporter arrives, I understand that I may not have another opportunity to obtain this service.

    19. I understand that based on this information and the data I have provided; Iredell County Emergency Management and the NC Division of Emergency Management will determine if any emergency evacuation assistance will be provided.

    20. I understand that power is not guaranteed, due to unforeseen power fluctuations or power failures.