Fields marked with a red * are required. You will need your MyLifeCard group number to complete this application.
First Name*   
Middle Name
Last Name* Suffix
Address* Apt #  
City* State* Zip*
Phone* -- Email*
Sex* Marital Status*
Birth date* / / (YYYY Format)
 
Order Number from Shopping Cart:
Item # from shopping cart (enter numeric portion only)* MLC- 
Social Security Number* --
Primary Insurance: Secondary Insurance:
Carrier Carrier  
Policy #  Policy #  
Phone -- Phone --

Primary Emergency Contact:
Secondary Emergency Contact:
Name* Name
Address* Address
City* City
State* Zip* State Zip
Phone * -- Phone --

Physician:
Name Do you wish to be a blood recipient?*
Yes No

Do you wish to be an organ donor?*
Yes No
Address
City
State Zip
Phone --
 
Allergies:
 Medications:
 Medical Conditions:

Religion*

Please choose a password:
Password*
 Confirm Password*
Authorization for Internet Access*
(In compliance with HIPAA rules and regulations)

In order to make my health information available to Medical personnel in the fastest way possible, I authorize MyLifeCard International, Inc. to transmit this information by means of the Internet. Since MyLifeCard International, Inc. agrees to use its best efforts to assure that there will be no unauthorized access, I agree not to hold MyLifeCard International, Inc. responsible for any violation by any unauthorized person.

While I may revoke this permission for Internet Access I cannot hold MyLifeCard International, Inc. responsible for any transmission sent prior to MyLifeCard International, Inc.’s receiving such notice.

MyLifeCard International, Inc. disavows any liability for incorrect information supplied by any member and I hold harmless MyLifeCard International, Inc. for any damages arising there from.

I have read and agree to these terms.

Advance Medical Directive (Optional)
Following are three general statements about withholding and removal of life-sustaining treatment. After carefully reading all three of these statements, if you agree with one of them you may select that option. IF YOU DO NOT CHOOSE ANY ONE OF THE FOLLOWING STATEMENTS, ALL LIFE-SUSTAINING DECISIONS WILL BE MADE BY YOUR PHYSICIAN, FAMILY OR DESIGNATED AGENT.

Option 1: I want efforts to prolong my life and life-sustaining treatment to be provided even if I am in an irreversible coma or persistent vegetative state.

Option 2: I want efforts to prolong my life and life-sustaining treatment to be provided unless I am in a coma or persistent vegetative state, which my doctor reasonably believes to be irreversible. Once my doctor has concluded that I will remain unconscious for the rest of my life, I do not want life-sustaining treatment to be provided or continued.

Option 3: I do not want efforts to prolong my life and do not want life-sustaining treatment to be provided or continued: [1] if I am in an irreversible coma or persistent vegetative state; or [2] if I am terminally ill and the application of life-sustaining procedures would serve only to artificially delay the moment of death; or [3] under any other circumstances where the burdens of the treatment outweigh the expected benefit. I want my agent to consider the relief of suffering and the quality, as well as the extent of the possible extension of my life in making decisions concerning life-sustaining treatment.