Brown County Fall Prevention Program-Green Bay Metro Fire Dept

Green Bay Metro Fire Department

Please complete the form below to submit fall data and referral for follow-up assistance
ADRCBuilding Concern (GBMFD use only)Adult Protective Services (APS)MIH (GBMFD only)
GBMFD Rig*
Gender
Contact:*

First NameLast Name
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Contact...if needed for further information.
Relationship
Contact:

First NameLast Name
Phone Number

Area CodePhone Number
- YES, please contact the individualNO, patient refused referral program at this time.
- Is current referral the result of a Fall?*
- Cause of Fall*
- Location of Fall*
- YesNo
- Occupancy Type:
- Describe Unsafe Condition:
- YESNO
- YESNO
- YESNO
- HSHS St Vincent HospitalHSHS St Mary's HospitalBellin HospitalAurora BayCare Medical Centerother (Describe in comments below)
- YESNO
- HoardingInfestationOther dangers
- NOYESUnknown
- YESContact Adult Protective Services M-F 8-4:30pm at 920-448-7885 or the emergency cell at 920-660-1486Contact Crisis Center after hours or weekends or holidays (APS backup) at 920-436-8888.NO
- Reason for APS referral from EMS/Fire if not covered:
- Description of the scene, weapons, etc.
- Comments
- DO NOT include any PHI, primary impression, etc. in the comments box.
- [PLEASE READ THIS TO THE PATIENT]
  
  The Aging and Disability Resource Center of Brown County and Green Bay Metro Fire Departments are teaming up to help you live at home more safely and decrease your risk of falls. Completion of this form allows the EMS or fire department to provide your contact information to the Aging and Disability Resource Center who will follow up with you at another time. The ADRC will provide you with information and programs that they have available. Your permission to make the referral does not require you to accept the services. You may decline their assistance at any time.
- HIPAA-consent form
  
  I authorize this EMS agency or fire department to disclose the above information to the Aging and Disability Resource for the purpose of seeking services.
  
  By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
  
  By signing this form, I understand that:
   Protected health information may be disclosed or used for treatment or healthcare operations.
   The practice reserves the right to change the privacy policy as allowed by law.
   The practice has the right to restrict the use of the information but the practice does not have to agree to those
  restrictions.
   The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
   The practice may condition receipt of treatment upon execution of this consent.
- Signature*
- Date
  
  MonthDayYear
- Should be Empty:

Green Bay Metro Fire Department