DELAWARE HEALTH AND SOCIAL SERVICES 
Division of Public Health
Office of Emergency Medical Services
 
DELAWARE EMERGENCY MEDICAL SERVICES FOR CHILDREN

Consent for Enrollment in the Special Needs Alert Program (SNAP) 

The Delaware Emergency Medical Services for Children program for Children with 
Special Healthcare/Medical Needs will keep all information provided on the Emergency 
Information Form and the Home Visit Form confidential, pursuant to the Federal Health 
Insurance Portability and Accountability Act (HIPAA) of 1996, and effective Nationwide 
as of April 14, 2003.
 
Each Ambulance Service throughout the State of Delaware is required to present you 
with a Notice of their operation’s Privacy Practices, as well as explain to you your rights 
under the Federal HIPAA laws and guidelines when visiting your home to obtain the 
above-referenced information for this program. In addition, all emergency medical 
personnel involved in responding to a medical emergency regarding your child are 
required to follow all privacy practices and stipulations in place, and cannot discuss, or 
disseminate in any form, any Protected Health Information (PHI) regarding your child, 
unless it is imperative to administering care required within the scope of their medical 
duties where your child is concerned. 

By signing below, you acknowledge understanding that the information provided on the 
attached Emergency Information Form/Home Visit Form may be shared with emergency 
medical field responders to aid them in providing the necessary emergency medical care 
to your child and that you have received a copy of the local EMS agency privacy 
practices.
 
As a result of the forms being used to provide a more complete medical record for your 
child, there is a potential for this protected health information to be redisclosed to other 
non-HIPAA covered entities. 

Failure to sign this form will not ever result in denial of normal processing of emergency 
calls or denial of any medically necessary emergency treatment. Please feel free to 
contact the Ambulance Service at ________________, the County EMS Agency at 
_________________or the Emergency Medical Services for Children program in the 
Division of Public Health 302-744-5400 for any questions about the consent form or the 
SNAP. 

By signing below, I give permission to share the Emergency Information Form and Home 
Visit Form information, (to be obtained by emergency medical field responders if a home 
visit occurs) to necessary emergency medical staff so that they may provide all necessary 
emergency medical care to my child. I also acknowledge that I have received a copy of 
this completed consent form and local EMS agency privacy practices. I understand that I 
may revoke this statement in writing at any time, except to the extent that the 
organization named above has already taken action on this authorization. To revoke this 
statement notify in writing your local county EMS agency stating that you wish to 
withdraw your child from the “Special Needs Alert Program.” Include your 
correspondence to the county EMS agency: the name of the child, the date of birth and 
the address.

____________________________________    ___________________________________    ___________ 
Parent/Guardian (Print Name)            Parent/Guardian (Signature)            Date 
or Legal Custodian                      or Legal Custodian 


_________________________
Relationship to the child


____________________________________    ____________________________________    ___________     
Witness (Print Name)                    Witness (Signature)                     Date 

This Consent for Enrollment is effective for one year from the date of signature. A new 
consent and updated health forms will be required to continue in the Special Needs Alert 
Program after one year. 

DELAWARE HEALTH AND SOCIAL SERVICES 
Division of Public Health
Office of Emergency Medical Services 
Easter Seals

This project was supported in part by grant number 1 H33 MC00112-03 from the Department of Health 
and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 

Doc. #35-05-20/07/03/23