Form Center

I certify that this information is correct. I understand that based on this application and the data I have provided, Beaufort County Emergency Services will determine which emergency and 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. I grant permission to medical providers, transportation agencies, and other individuals providing me with assistance and disclose any information required to respond to my needs. 

I understand that I have the right to revoke this Authorization at any time, except to the extent that Beaufort County has already acted in reliance on the Authorization.  
 
To revoke this Authorization, I understand that I must do so by written request to the Beaufort County Office of Emergency Services, at 1420 Highland Dr, Washington, NC, 27889. Attention: Access and Functional Needs Registry.

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 Beaufort County in order to provide me with 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.