Standard Medical Information Form

TITLE 39 HEALTH AND SAFETY CHAPTER 47 YELLOW DOT MOTOR VEHICLE MEDICAL INFORMATION ACT 39-4706. STANDARD MEDICAL INFORMATION FORM. (1) The department is authorized to create a standard medical information form providing space for each participant to supply, at a minimum, the following information: (a)  The participant’s name; (b)  A photograph of the participant; (c)  Two (2) emergency contacts identified by the participant and their contact information; (d)  The participant’s relevant medical information, including medical conditions, recent surgeries, allergies, and medications; (e)  The participant’s hospital preference; (f)  Up to two (2) preferred physicians identified by the participant and their contact information; and (g)  The date on which the participant completed the form. (2)  The medical information form shall include a statement that the yellow dot program functions only as a facilitator and that all information supplied on the medical information form is the sole responsibility of the participant. (3)  The medical information form shall also include statements that the participant supplies the medical information voluntarily and that the participant authorizes the disclosure to, and use of, such medical information by emergency medical responders and other responders for the purposes described in section 39-4708 , Idaho Code.