LEDS Law Enforcement Data System Enrollment Consent Form

The information in this form will be entered into the Law Enforcement Data System to help the responding agencies assist persons with a qualifying illness or condition in obtaining medical, mental health and social services when responding to a request for an emergency service. The information will only be accessed to provide necessary information to responding law enforcement officers and other responding emergency personnel to assist in an emergency situation.

By completing this form the signer is authorizing the release of protected health information to law enforcement agencies and other emergency responders.

If you have any questions on the form or process, please contact Tanya Thompson at 541-967-3866 extension 2304.

This document can also be provided upon request in alternative formats for individuals with disabilities. Other formats may include (but are not limited to) large print, Braille, audio recordings, Web-based communications and other electronic formats. E-mail Oregon DHS or visit the Oregon DHS Alternative Formats and Translations website for more information.