To the extent that any information provided in this form constitutes Protected Health Information, I hereby authorize and consent to its release to any emergency response personnel of, but not limited to, the Carmel Fire Department, the Carmel Police Department, and the Hamilton County Public Safety Communications (9-1-1 dispatch), to be used to assist emergency response personnel in case of an emergency.
- This consent is subject to revocation at any time by notifying the Carmel Fire Department in writing, except to the extent that action has been taken in reliance on the consent.
- Any future treatment, payment, enrollment, or eligibility for benefits is not conditioned upon whether or not this release is authorized and/or consented to.
- There is potential that information disclosed under the terms of the authorization will be redisclosed by the recipient and no longer protected by 45 CFR Part 164, Subpart E.
I understand that, by providing the above information, a state, county, or municipal emergency responder, including any present and former officer, agent, and/or employee of, but not limited to, the Carmel Fire Department, the Carmel Police Department, and the Hamilton County Public Safety Communications (9-1-1 dispatch), does not assume any responsibility or duty beyond that which is provided for under applicable law.
I agree to provide timely written notice to the Carmel Fire Department of any changes to the information provided above, including, but not limited to, a change of residence or a change to the specific need(s) of the Resident.
I affirm, under penalty of perjury, that the information provided above is accurate and true to the best of my knowledge, and understand that if I have intentionally or knowingly provided incorrect information I may be subject to criminal and/or civil liability.
This information, included the consent, WILL expire every 12 months. In order to remain part of the Specific Response Registry, this form must be completed every 12 months.
I understand that my electronic signature constitutes a legal signature confirming that I acknowledge and agree to the above.