Medicare Sign Up pack sample

Your family may not be together when disaster strikes, so plan how you will contact one another and review what you will do in  different situations.  (make copy of this information for every family member)   (INSTRUCTIONS: COMPLETE THIS DATA SHEET, OR ASK A FAMILY MEMBER TO HELP YOU TO COMPLETE THIS INFORMATION) Out of Town Contact Name: ______________________________________________________________   Email:_______________________________________________________________________________  Tel. Number 1:_________________________________________   Tel. Number 2:_________________________________________  Fill out the following information for each family member and keep it up to date.  Name: _______________________________________________________________________________  Social Security Number: __________________________________  Date of Birth: ___________________________________________  Important Medical Information: ____________________________________________________________  _____________________________________________________________________________________  Name: _______________________________________________________________________________  Social Security Number: __________________________________  Date of Birth: ___________________________________________  Important Medical Information: ____________________________________________________________  _____________________________________________________________________________________  Name: _______________________________________________________________________________  Social Security Number: __________________________________  Date of Birth: ___________________________________________  Important Medical Information: ____________________________________________________________  _____________________________________________________________________________________  Name: _______________________________________________________________________________  Social Security Number: __________________________________  Date of Birth: ___________________________________________  Important Medical Information: ____________________________________________________________  _____________________________________________________________________________________  Name: _______________________________________________________________________________  Social Security Number: __________________________________  Date of Birth: ___________________________________________  Important Medical Information: ____________________________________________________________  _____________________________________________________________________________________  Where to go in an emergency.  Write down where your family spends the most time:  Work: ________________________________________________________________________________  School and other places you frequent: ______________________________________________________  _____________________________________________________________________________________  Daycare providers ______________________________________________________________________  Workplaces and apartment buildings should all have site‐specific emergency plans  _____________________________________________________________________________________  Doctors: ______________________________________________________________________________  _____________________________________________________________________________________  Pharmacy: ____________________________________________________________________________  Medical Insurance: ______________________________________________________________________  _____________________________________________________________________________________  Homeowners/Rental Insurance: ___________________________________________________________  Veterinarian: __________________________________________________________________________  FAMILY COMMUNICATION PLAN (Emergency/Disaster Plan) page 20 sample