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Emergency Information

Whether you live long distance or are directly caring for your loved one, it is important to have detailed information readily at hand for emergency purposes. You must know what documents are needed and where they are located. This information should be accessible for yourself and those who will be caring for your loved one if you are not available.

Please remember to keep all this information up to date. By preparing this information, you be insuring that you are better prepared should emergencies arise. We encourage you to print out these pages, keeping them in a safe place, preferably a binder or envelope. Click on the links to access the forms for printing

Carerecipient:
Name:_____________________
Nickname:_______________
.
Address______________________________________________
City:_____________________
State: _______
Zip: ________
Phone:__________________
Social Security #:_________________Blood Type: ____
Disease(s)/ Illness/ Condition:
_____________________ _______________________
______________________ _____________________ _______________________
Organ Donation Status: __________________________________________________
Other Important Info: _____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Caregiver:
Name:_____________________
Nickname:_______________
Address______________________________________________
City:_____________________
State: _______
Zip: ________
Home Phone:_________________Business Phone:________________ Ext:  ___
Relationship To Carerecipient: ____________

Caregiver:
Name:_____________________
Nickname:_______________
.
Address______________________________________________
City:_____________________
State:_______
Zip: ________
Home Phone:_________________
Business Phone:________________ Ext:  ______
Relationship To Carerecipient: ____________

Emergency Phone Numbers:
911
Police: __________________
Fire: ________________
Ambulance: _______________ Hospital: __________________
Others: ______________________________________________________________


Spouse, Significant Other, Relative, Friend or Neighbor:
Name:_____________________
Nickname:_______________
Address______________________________________________
City:____________________
State:_______
Zip:________
Home Phone:_________________
Business Phone:________________ Ext:  ___
Relationship To Carerecipient: ____________

Spouse, Significant Other, Relative, Friend or Neighbor:
Name:_____________________
Nickname:_______________
Address______________________________________________
City:_____________________
State:_______
Zip:________
Home Phone:_________________
Business Phone:________________ Ext:  ___
Relationship To Carerecipient:____________

Doctor(s):
Name:________________________________
Address______________________________________________
City:_____________________
State: _______
Zip: ________
Home Phone:_________________
Business Phone:________________ Ext:  ___
Type Of Doctor: ____________

Name:________________________________
Address______________________________________________
City:_____________________
State: _______
Zip: ________
Home Phone:_________________
Business Phone:________________ Ext:  ___
Type Of Doctor: ____________

Name:________________________________
Address______________________________________________
City:_____________________
State: _______
Zip: ________
Home Phone:_________________
Business Phone:________________ Ext:  ___
Type Of Doctor: ____________

Pharmacy
Name:________________________________
Address______________________________________________
City:_____________________
State: _______
Zip: ________
Phone:________________ Hours: ____________________________________
Medications: ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________
Allergies ____________ ________________ _________________
Allergies To Medications: ______________ _______________ _______________
Special Instructions: _______________________________________________________________ ________________________________________________________________________________

Health Insurance Company(s)
:

Medicare
Policy #: ___________________________                                                  Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip:_________

Medicaid
Policy #: ___________________________                                                   Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip:_________

Medigap
Policy #: _________________________________________                           Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City:__________________________ State: _________ Zip:_________

Workers Compensation
Policy #: ___________________________                                                   Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip:_________

Social Security Disability
Policy #: ___________________________                                                   Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip:_________

Veterans Administration

Policy #: ___________________________                                                   Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip:_________

Other
Policy #: ___________________________                                                  Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip:_________


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