I certify that this information is correct. I understand that based on this application and the data I have provided,
the St. Johns County Department of Emergency Management (SJCDEM) will determine which emergency evacuation assistance,
if any, this program may be able to provide. I understand that there is no cost associated with using any of the
County’s disaster evacuation centers or disaster transportation services. However, should my medical condition
deteriorate and should I be admitted to the hospital, while being evacuated or at an evacuation center,
then I will be responsible for the charges incurred once I am “admitted as a patient” of a hospital.
I grant permission to medical providers, transportation agencies and other individuals providing me medical care and
disclose any information required to respond to my needs.
HIPAA Privacy Rule:
As defined in the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule
of 1996, by signing this Authorization, I hereby allow the use or disclosure of my medical information by SJCDEM,
in order to provide me assistance during emergency evacuations.
I understand that information used or disclosed pursuant to this Authorization, may be subject to disclosure by the
recipient for the purposes of evacuation, sheltering, transportation and any medical care pursuant to these services.
I understand that I have the right to revoke this Authorization at any time except to the extent that SJCDEM
has already acted in reliance on the Authorization. To revoke this Authorization, I understand that I must do
so by written request to:
St. Johns County Department of Emergency Management
100 EOC Drive
St. Augustine, Florida 32092
Attention: Evacuation Assistance Registry
I understand that if I choose to revoke this Authorization, I will no longer be part of the Evacuation
Assistance Registry and will not be evacuated.