Decatur County Home Use Medical Device Database
This database has been created as a joint effort between Decatur County Public Health and Decatur County Hospital to compile a list of residents who are dependent upon home medical devices. The database will be confidential. Decatur County Public Health and Decatur County Hospital will share the information collected on the database, between themselves and with local Emergency Services personnel (Law Enforcement/Fire-Rescue/EMS), for purposes of responding to an emergency incident in which Decatur County Hospital, Decatur County Public Health staff or other emergency response personnel will conduct well-being checks on those citizens listed in the database.

Example: Ice Storm
Staff will contact citizens listed in the database to assure their welfare during such an incident, and make arrangements for needs that may arise; including transport to a safe area.

Name *
Street Address *
City of Residence
Phone *
Emergency Contact Information
Provide contact information (Name/Address/Phone) of who you'd like contacted in the event of an emergency.
Do you have any medications stored in limited supply, that may be life threatening if not readily available in an extended incident?
Do you have any medical devices that require electricity that could be life threatening in an extended power outage?
Does your device have battery back-up?
Would you require access to a facility with generator power?
Consent to Release Information
By clicking submit, I agree that the information I have submitted may be shared with Decatur County Public Health and Decatur County Hospital as well as between themselves and released to local Emergency Services personnel listed below for purposes of responding to an emergency incident in which Decatur County Hospital or Decatur County Public Health staff will conduct well-being checks on those citizens listed in the database. I agree my information may be shared with the following agencies: Decatur County Hospital, Decatur County Public Health, Decatur County Sheriff's Office, Decatur County Emergency Management Agency, Decatur County Community Emergency Response Team (CERT), Leon Fire & Rescue, Leon Police Department, Lamoni EMS, Lamoni Police Department, Grand River EMS and Garden Grove EMS.
Authorization to Revoke
This authorization may be revoked at any time, except to the extent that action has been taken in reliance upon it. Revocation must be made in writing to Decatur County Hospital. Neither Decatur County Hospital nor Decatur County Public Health will condition treatment on whether the authorization is signed. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the same federal and state laws. This authorization will continue until revoked or upon death.
You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any document, agreement, acknowledgement, consent, term, disclosure, or condition constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Decatur County Hospital. *
By typing your name you agree the above statement.
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