WNY Mutual Aid

Western New York Health Care
Mutual Aid Plan
Application for Membership

Thank you for considering joining the Western New York Mutual Aid Plan. The mutual aid plan is designed for those disasters where an unpredictable event requires the immediate evacuation of residents. It is not designed as part of a contingency plan for long term resident evacuation due to employee strike or closure of a health care facility. The commitment to this Plan (caring for evacuated residents) is for two weeks or less, unless approved for a longer term by the Plan member and the NYS Department of Health.

Dues Structure

New Members:
Initial membership fee $300.00		Annual Dues $100.00

Current Members:
Annual Dues $100.00

Please make checks payable to: WNY Mutual Aid Plan Western New York Mutual Aid Plan Steering Committee Michelle Murtha, Administrator "Greenfield Health & Rehab. Center 5949 Broadway Avenue Lancaster, NY 14086 Ph.: 684-3000; Fax: 684-3380 mmurtha@niagaralutheran.org

How may we help you?

Other:

Enter your comments in the space provided below:

Facility
Your Name
Your E-mail Address


Please the following field(s).
Facility Name
Address
Telephone number
Fax number
Cell phone
E-mail address
Contact's Name
Contact's Title
Type of Facility

Stop over point (local fire hall / school)
Address
Phone number
Capacity to receive (10% of your facility)

Transportation (i.e. 1 van 3 pass. + 4 W/C)

Special Care Provided (Select all that apply)
Special Care Provided (Select all that apply)
A - IV care
B - Ventilator Care
C - Tube Feeding
D - Active Isolation
E - Hickman Catheters
F - Daily Peritoneal Dialysis
G - Trach Care
H – Bariatric Residents
I – Passey Muir Valve
J – PICC Line, Central Line
K – Wandering Residents
L – Physically Aggressive
M – Rehab.
N – Ortho
O – Traumatic Brain Injured
P – TPN
Q – Complex Dressing
R – Psychiatric Matters
S – CPR Certified Staff 24/7