New ICE Contract Amendments:
Terms & Conditions:
I understand that by signing this form I am authorizing ICE USA, Inc. and its
agents to release any provided medical information of the ICE USA, Inc. Member or Members.
I understand that authorizing the disclosure of this health information is
voluntary. I understand that I am not required to sign this agreement/authorization.
I understand that I have the right to revoke this agreement/authorization at
anytime. I understand that if I revoke this agreement/authorization that I must
do so in writing and present my revocation to the ICE USA, Inc. Member Services
Department. I understand that revocation will not apply to information that has
already been released in response to this authorization.
I understand that the information contained in this agreement/authorization is
good for a period of 1 year from the date of signature. I understand that it
is the sole responsibility of the ICE USA, Inc. Member or Members to renew and
update this agreement/authorization.
I understand that it is the sole responsibility of the Member and/or Members to
inform ICE USA, Inc. of any changes in medical conditions, medications,
allergies, or any personal wishes as expressed in this agreement/authorization.
I understand that ICE USA, Inc. will make any and all attempts necessary to
establish contact with the ICE USA, Inc. Member and/or Members designated
Contacts in the event that a verified emergency incident has occurred. I
understand that ICE USA, Inc. will not be held liable for failure to establish
contact with any of the above listed Contacts utilizing the Contact information
provided in this agreement/authorization.
I understand that I have the right to inspect and/or receive copies of the
information contained in this agreement/authorization to be used or disclosed.
I understand that a photocopy of this agreement/authorization shall be valid
as the original.
I understand information contained in this agreement/authorization can be
added or changed anytime with the written consent of the ICE USA, Inc.
Member or Members by completing an ICE USA, Inc. Change of Information
official form. The ICE USA, Inc. Change of Information form can be
downloaded from the ICE USA, Inc. website, www.icecontactusa.com, or
obtained by request by calling 1.877.564.6423.
I understand that ICE USA, Inc. will make every effort within reason to
verify the existence of an actual emergency situation involving the ICE
USA, Inc. Member or Members in this agreement/authorization before
attempting to make contact with any of the designated emergency contacts
listed in this agreement/authorization. Should ICE USA, Inc. become
unable to verify an emergency situation, ICE USA, Inc. will not pursue
any attempts to establish contact with any emergency contact.
I understand that ICE USA, Inc. will not be held liable for failure of
emergency first responders to utilize the services offered by ICE USA,
Inc. It is neither the responsibility nor the priority of Emergency
First Responders, including but not limited to; police, fire, EMR, EMS,
or hospitals, to utilize the services offered by ICE USA, Inc.
Disclaimer:
The services of ICE USA, Inc. should never take precedence over the
rendering of emergency medical attention on behalf of the ICE USA, Inc.
Member or Members/Victim. The services offered through ICE USA, Inc.
should only be utilized once the proper authorities deem the emergency
situation has become stable.
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