A Guide for People with

AUTONOMIC DYSREFLEXIA:
WHAT YOU SHOULD KNOW

Consortium for Spinal Cord Medicine

Administrative and financial support provided by Paralyzed Veterans of America

What to Do If You Think You Have Autonomic Dysreflexia:

Prompt action is essential! If you cant follow these steps yourself, tell a family member, an attendant, or a friend what to do. Its important to do these steps in the order below. 1. Sit up, or raise your head to 90 degrees. If you can lower your legs, do.

Important: You need to stay sitting or upright until your

blood pressure is back to normal.

2. Loosen or take off anything tight:

s s s

4. Check to see if your bladder is draining properly (see page 4, step 4). 7. At the emergency room, make sure you:
s s s s

5. Call your health-care professional, even if the warning signs go away. Report the symptoms you had and what you did to correct the problem. 6. If the warning signs come back again, repeat these steps. Even if the warning signs go away again, call your health-care professional and go to the emergency room. Tell the emergency room staff that you think you may have autonomic dysreflexia and need immediate treatment. Ask to have your blood pressure checked immediately. Request to keep sitting up as long as your blood pressure is high. Ask the emergency room staff to look for causes of the problem. Suggest that they check for causes in this order: (1) bladder, (2) bowel, and (3) other causes. Suggest that your health-care professional instill anesthetic jelly into your rectum before checking your bowel. complete clinical practice guideline available at the website: www.pva.org.

3. If you have a blood pressure kit, take your blood pressure reading about every 5 minutes to see if youre getting better.

External catheter tape Clothes Elastic hose or bandages

s s s

Abdominal binders Shoes or leg braces Leg bag straps

Important: Inform the emergency room staff that there is a

AUTONOMIC DYSREFLEXIA: WHAT YOU SHOULD KNOW

A Guide for People with Spinal Cord Injury

Contents
Who Should Read This Guide?.............................................................. 1 What Causes Autonomic Dysreflexia? .................................................. 2 If I Think I Have Autonomic Dysreflexia, What Should I Do?............ 3 Sidebar: Bladder Management Tips .............................................. 4 Sidebar: Talk About It ......................................................................6 Why Is This Guide Important?.............................................................. 1 Sidebar: Quick Overview..................................................................1 Acknowledgments....................................................................................ii

What Is Autonomic Dysreflexia? .......................................................... 1 What Are the More Common Warning Signs?...................................... 2 Sidebar: Heres What Happens in Autonomic Dysreflexia ............2

Table: Common Causes of Autonomic Dysreflexia: ............................ 8 Glossary................................................................................................ 10 My Personal Autonomic Dysreflexia Diary ........................................ 11

What Goes in an Autonomic Dysreflexia Kit?...................................... 7

The information in this Guide is not intended to substitute for prompt professional care. If you develop warning signs of autonomic dysreflexia, contact a physician or other appropriate health-care professional as soon as possible. This Guide has been prepared based on scientific and professional information known about autonomic dysreflexia, its causes, and treatment, in 1997. It is recommended that you periodically review this Guide with health-care professionals from whom you regularly receive care.
Consortium for Spinal Cord Medicine Administrative and financial support provided by the Paralyzed Veterans of America August 1997 Copyright 1997, PARALYZED VETERANS OF AMERICA

Acknowledgments
The Consortium for Spinal Cord Medicine for development of clinical practice guidelines is composed of 17 organizations interested in spinal cord injury care and treatment. The Consortium Steering Committee established a guideline development panel to make recommendations on how best to prevent and treat autonomic dysreflexia because of its life-threatening nature. The consumer panel was chaired by Todd A. Linsenmeyer, M.D., and consisted of nine members with experience in autonomic dysreflexia from varying health care professions. The recommendations are based on the world-wide research information available on the topic. The panel was assisted by an expert team from the University of North Carolina at Chapel Hill who reviewed the literature and determined the quality of the research. The Paralyzed Veterans of America provided financial support and administrative resources for all aspects of guideline and consumer guide development. The guideline development process leads to professional agreement on a topic. After the panel writes their guideline recommendations, many outstanding clinical and scientific experts review the draft guideline. The panel accepts or rejects the reviewers opinions by voting and prepares the final guideline for legal review and editing. In the development of consumer guides, a consumer focus group of six or more spinal cord injured individuals reviews the guide with the panel to make it more readable and easy to understand. The Consortium for Spinal Cord Medicine is appreciative of the fine work of the guideline development panel, the expert field reviewers, and the writers, editors, and consultants that contributed to the content and quality. In particular, the Consortium would like to recognize the outstanding contribution by the American Association of Spinal Cord Injury Nurses (AASCIN) in providing their consumer and family education material.

Consumer Panel Members

Todd A.Linsenmeyer, MD Chair and Steering Committee Liaison Kessler Institute for Rehabilitation West Orange, New Jersey Departments of Surgery (Urology) & Physical Medicine and Rehabilitation UMDNJ; New Jersey School of Medicine Newark, New Jersey Andrea K.Biddle, PhD, MPH Methodologist Department of Health Policy & Administration School of Public Health University of North Carolina Chapel Hill, North Carolina Diana Cardenas, MD Department of Rehabilitation Medicine University of Washington School of Medicine Seattle, Washington Teresa Chase, ND, RN Craig Hospital Englewood, Colorado Kathleen Dunn,MS,RN VA San Diego Healthcare System San Diego, California Keri S. Jaeger, MBA,RN Froedtert Memorial Lutheran Hospital Milwaukee, Wisconsin Tom Mobley, PharmD James A. Haley Veterans Hospital Tampa, Florida Inder Perkash,MD Department of Veterans Affairs Medical Center Palo Alto, California Cynthia Zejdlik,RN Independent Rehabilitation Nursing Consultant Bellingham, Washington

Consortium Member Organizations

American Academy of Orthopedic Surgeons American Academy of Physical Medicine and Rehabilitation American Association of Neurological Surgeons American Association of Spinal Cord Injury Nurses American Association of Spinal Cord Injury Psychologists and Social Workers American Congress of Rehabilitation Medicine American Occupational Therapy Association American Paraplegia Society American Physical Therapy Association American Psychological Association American Spinal Injury Association Association of Academic Physiatrists Association of Rehabilitation Nurses Congress of Neurological Surgeons Insurance Rehabilitation Study Group Paralyzed Veterans of America U.S. Department of Veterans Affairs

The Consortium will continue to develop clinical practice guidelines and consumer guides on topics in spinal cord injury care. Look for consumer guides on other topics in spinal cord injury.

ii

Who Should Read This Guide?

s

What Is Autonomic Dysreflexia?

Autonomic dysreflexia can be life-threatening. It requires quick and correct action. Unfortunately, many health professionals arent familiar with this condition. Thats why its important for you, and the people close to you, to learn about it. You may have to help guide your own treatment by ensuring that health-care professionals are thinking about autonomic dysreflexia when they are treating you. This is true if youre in an ambulance or at the hospital. Its a good idea to keep this Guide handy. You may want to take it with you to the hospital and share it with the emergency room staff. Its an abnormal response to a problem in your body below your SCI. The cause is often an overfull bladder or bowel. Because of your SCI, your body

Their family, friends, and personal care attendants Health-care professionals may obtain a copy of the full clinical practice guideline by calling tollfree (888) 860-7244 or at www.pva.org. If you have SCI at or above T-6, this Guide is for you. Why? Because you have a greater chance of developing a serious condition called autonomic dysreflexia.* If your injury is below T-6, this Guide may still be helpful. People with SCI as low as T-8 have sometimes developed autonomic dysreflexia. Even if youve already learned what to do for autonomic dysreflexia, you may want to keep this Guide for reference. It may be helpful for you or for people who share in your care.
s

People with spinal cord injury (SCI) at or above T-6

Quick Overview
Autonomic dysr eflexia is an emergency condition tha t needs immediate attention! Its most likely to occur if you have a spinal cord injury at or above thoracic level 6 ( T-6). Autonomic dysr eflexia is an abnormal response to a problem somewhere in your body. It's usually caused b y a bladder or bowel problem. Because of your SCI, your body can't respond properly to signals that something is wrong. Instead, you may develop a rapid rise in blood pressure. High blood pres -

Why Is This Guide Important?

sure is a serious medical problem. It can cause a stroke and death.

*Words in italics are explained in the Glossary on page 10.

Heres What Happens in Autonomic Dysreflexia

1.

AUTONOMIC DYSREFLEXIA: WHAT YOU SHOULD KNOW

Something is wrong. It s often an overfull bladder or bowel. This causes your body to send messages to your spinal cord.

2. Your spinal cord tries to send the messages to your brain. But your SCI blocks the messages from getting through. (Thats why you probably cant feel the pain.) 3. The messages to your spinal cord turn on spe cial autonomic nerves. They make blood vessels in your legs and abdomen squeeze tight and get smaller . 4. This squeezes extra blood into blood vessels in the rest of your body. The extr a blood makes your blood pressure go up fast. 5. Sensors near your brain can tell that your blood pressure is getting too high. They try to make your blood pressure go down b y sending out three signals:
(continued)

cant respond properly to signals that something is wrong. (Common warning signs that you might have autonomic dysreflexia are listed below.) The important thing for you to know is that autonomic dysreflexia can be dangerous. It can cause a rapid rise in blood pressure. High blood pressure is a serious medical problem. It can cause a stroke and death. There are two ways you may get your blood pressure down: 1. Fix whatever is causing the problem 2. Special blood pressure medicines prescribed by your health-care professional

What Causes Autonomic Dysreflexia?

Bladder problems are the number one cause of autonomic dysreflexia. But any problem below your SCI can cause this condition. Some of the more common causes are listed in the table on pages 89. You can avoid most of these causes by taking good care of yourself. The table lists things you can do to prevent autonomic dysreflexia.

What Are the More Common Warning Signs?

Although its possible to have no symptoms, most people do. Watch for one or more of the following more common warning signs:
s

Important: Individuals blood pressures vary. If

A fast, major increase in blood pressure is the most dangerous sign of autonomic dysreflexia. A major increase is 2040 mm Hg higher than usual. Many individuals who have SCI at or above T-6 have a blood pressure between 90 and 110 mm Hg systolic. (Systolic is the top number in a blood presyou dont know what your normal blood pressure is, it is important that you find out.

A pounding headache s Heavy sweating, especially in your face, neck, and shoulders. This is usually (but not always!) above your spinal cord injury s Flushed or reddened skin, especially in your face, neck, and shoulders. This is usually above your spinal cord injury s Goose bumps, usually above your spinal cord injury s Blurry vision or seeing spots s A stuffy nose s Anxiety or jitters s A feeling of tightness in your chest, flutters in your heart or chest, or trouble breathing While there may be other warning signs, these are the more common. If any of them appears, or if your blood pressure rises 2040 mm Hg systolic, assume you have autonomic dysreflexia. Follow the steps in the next section.
s

sure reading.)

A GUIDE

FOR

PEOPLE WITH SPINAL CORD INJURY

Heres What Happens

(continued)

Signal 1

tells your heart to slow down. (A slow heart beat is called bradycardia.) Signal 2 goes to blood vessels in your face, neck, and upper chest. It makes them get larger and hold more blood. This can make you look flushed or red and blotchy . Signal 3 tries to tell the blood ves sels in your legs and abdomen to stop squeez ing. But your SCI blocks the messages from getting through. Your blood vessels keep squeezing, and your blood pressure stays high. It may even keep rising.

If I Think I Have Autonomic Dysreflexia, What Should I Do?

Step

Important: You need to remain sitting or upright

until your blood pressure is back to normal. Lying down may make your blood pressure go up higher.

Prompt action is essential! If you cant follow these steps yourself, ask someone else to do so. Its important to do these steps in the order below.

Sit up or raise your head to 90 degrees. If you can lower your s Clothes legs, do. s Shoes or leg Loosen or take off anything tight: braces s External catheter tape s Leg bag straps

Step

Bladder Management Tips

s Drink enough fluids. Ask your health-care profes sional about the right

AUTONOMIC DYSREFLEXIA: WHAT YOU SHOULD KNOW

s

Step

amount for you. You want to keep flushing out your bladder without letting it get overfull. s If your urine is cloudy, has a bad smell, or has blood in it, call your health-car e professional right away . You probably have a bladder infection. s Be careful with drinks tha t have caffeine or alcohol. They can make your bladder fill up suddenly and cause you to get dehydr ated. s Checkups (often done year ly) may include bladder tests. Ask if your healthcare professionals hav e experience with autonomic dysreflexia. Share this information and make a plan with them be forehand. If you use intermittent catheterization: s Stick to your schedule . Don't skip catheter sessions .

Abdominal binders s Elastic hose or bandages

See A (below) if you do intermittent catheterization or use an external catheter. 1. Take off the external catheter or pads. 2. If you (or someone with you) has experience inserting a catheter: Get a catheter. Coat it with an anesthetic jelly (if available) or a lubricant jelly. Insert it and empty your bladder promptly. 3. Stop trying to catheterize your bladder if: Theres no one with experience at inserting a catheter. The catheter wont slip in easily. Your symptoms get worse.

Check your bladder.

See B (below) if you have an indwelling catheter A. If you do intermittent catheterization, or use an external catheter or padding:

If you have a blood pressure kit, take your blood pressure reading about every 5 minutes to see if youre getting Step better.

(continued)

4. If you can insert another catheter and

Instead, call a health-care professional and go to the emergency room right away. Call 911 or have someone take you. Its dangerous for you to drive if you have autonomic dysreflexia.

B. If you have an indwelling catheter (a Foley or suprapubic catheter):

5. Check your urine for blood, odor, or cloudiness. If you find any of these things, call your health-care professional right away. You probably have a bladder infection. 2. Empty the drainage bag. 1. Check the tubing for kinks or twists. If you find any, fix them. If the tubing is stretched or pulling, relax it. Then tape it to keep it from pulling. stop irrigating. Call your health-care professional and go to the emergency room right away!

your blood pressure remains elevated, go to the emergency room right away.

A GUIDE

FOR

PEOPLE WITH SPINAL CORD INJURY

Bladder Management Tips

(continued)

s Keep your fluids to about 8 ounces (1 cup, 240 ml) an hour.

s If you drink more fluids than usual, catheterize early or add an extr a session. s Even though you may be tempted to cut back on fluids for convenience , don't. Youll increase your risk for urinary tract infection. If you have an indwelling catheter (a Foley or suprapubic catheter): s Check your drainage tube after transfers and turns . If you find any kinks or twists, fix them. Look for anything that clogs the catheter and clear it. s Make sure the drainage bag doesnt get more than half full. s Change your catheter regu larly. Learn how to change it yourself or make arrangements for someone to do it for you. Also, train someone who can change it in an emergency .

Important: If your symptoms get worse, immediately

3. If theres no urine flow, and you have experience irrigating your bladder, gen-

5. Stop trying to catheterize your bladder if: Theres no one with experience at inserting a catheter. The catheter wont slip in easily. Your symptoms get worse.

4. If theres still no urine flow and someone (you or anyone with you) has experience inserting a catheter:

Get another catheter. Coat it with an anesthetic jelly (if available) or a lubricant jelly. Insert the catheter into your bladder.

tly irrigate your bladder with saline solution. Use a small amount: no more than 2 tablespoons or 12 ounces (30 cc).

Instead, call a health-care professional and go to the emergency room right

Talk About It

AUTONOMIC DYSREFLEXIA: W HAT YOU SHOULD KNOW

Discuss autonomic dysr eflexia with your family, personal care attendants, and others who share in your car e. They need to know how to recognize it and help you if it occurs. And don't forget to bring up this subject with your health-car e professionals . If you're having tests , surgery, or a bab y, make sur e your health-care professionals are ready to monitor and man age autonomic dysr eflexia if it develops.

Important: If you need to go to the emergency

6. Check your urine for blood, odor, or cloudiness. If you find any of these things, call your health-care professional right away. You probably have a bladder infection. 7.If you can insert another catheter and your blood pressure remains high, go to the emergency room right away.

away. Call 911 or have someone take you. Its dangerous for you to drive if you have autonomic dysreflexia.

room, ask if you can sit up. Lying down may make your blood pressure go up.

Step

If the warning signs come back again, repeat these steps. Even if the warning signs go away again, call your healthStep care professional and go to the emergency room.
s

If the warning signs go away, call your health-care professional anyway, to report the symptoms you had and what you did to Step correct the problem.

At the emergency room, make sure you: Tell the emergency room staff that you think you may have autonomic dysreflexia and need immediate treatment.

What Goes in an Autonomic Dysreflexia Kit?

Its a good idea to make an "autonomic dysreflexia kit" and keep it

Use the diary form on pages 1114 and in the back pocket of this Guide to keep a record of your autonomic dysreflexia episodes. It can be helpful to you and to your health-care professionals.

Ask the emergency room Step staff to look for causes of the problem. Suggest that they check causes in this order: (1) bladder, (2) bowel, and (3) other causes.

Ask to have your blood pressure checked immediately.

s s

A GUIDE

A blood pressure kit.

Request to keep sitting up as long as your blood pressure is high.

This can be cuff style or digital style. Make sure that youor someone who can help in an emergency knows how to use it. A catheter and supplies.

with you at all times. Heres what it should contain:

FOR

PEOPLE WITH SPINAL CORD INJURY

If you use intermittent catheterization, or use an external catheter or padding, pack a straight catheter. If you use an indwelling catheter, pack: s an extra catheter s insertion supplies s an irrigation syringe
s

Any prescription medicines you take for autonomic dysreflexia. Check their expiration dates and keep fresh supplies in your kit. Anesthetic or lubricant jelly. A copy of this Guide.

sterile water or saline solution

Before you insert a catheter, coat it with the jelly. Keep your personal information current. (See the A u t o n o m i c Dysreflexia Diary on pages 11-14

AUTONOMIC DYSREFLEXIA IS A MEDICAL EMERGENCY!

You need to recognize it and get the right care fast.

Co m mon C aus e s of Au ton o mic D ys r e f l ex i a

WHAT CAUSES IT

AUTONOMIC DYSREFLEXIA: W HAT YOU SHOULD KNOW

HOW TO PREVENT IT
Follow a reliable bladder management routine. (See page 4, Bladder Management Tips.) Checkups (often done yearly) may include bladder tests. Ask if your health-care professionals have experience with autonomic dysreflexia. Share this information and make a plan with them beforehand.

BLADDER OR KIDNEY
Overfull bladder Problems such as urinary tract infection, or bladder or kidney stones Bladder tests, treatments, or surgery, such as cystoscopy and urodynamic tests

BOWEL* OR ABDOMEN Overfull bowel, constipation, or bowel blockage (impaction) Problems such as gallstones, stomach ulcer or gastritis, hemorrhoids, or appendicitis Bowel or abdominal tests or surgery, such as sigmoidoscopy or barium enema

Stick to your bowel program to prevent constipation or bowel accidents. (If constipation is a problem, you may need to change your bowel program.) Work with your health-care professional to determine what your usual fiber intake is. Any increase in fiber intake should be done gradually, from a wide variety of sources, and be monitored by a healthcare professional. Drink plenty of fluids. Ask your health-care professional about the right amount for you and your bladder program. Checkups (often done yearly) may include bowel tests. Ask if your health-care professionals have experience with autonomic dysreflexia. Share this information and make a plan with them beforehand.

* For more detailed information on bowel care, a complete bowel management clinical practice guideline is available at the website: www.pva.org or by calling toll-free (888) 860-7244.

SKIN Pressure sores (pressure ulcers) Problems such as ingrown toe nails, burns (including sun burns), or insect bites Contact with hard or sharp things or other injuries to the skin

Check your skin at least once a day for red spots, scrapes, or scratches below your SCI. If you find any, call your health-care professional right away. Try to avoid situations where youre likely to get burns, cuts, scrapes, or other injuries. Keep sharp or harmful things out of your bed and wheelchair. Make sure your clothes, shoes, appliances, and braces fit comfortably. Be especially careful if theyre new.

WHAT CAUSES IT
SEXUAL ACTIVITY OR REPRODUCTION Too much genital stimulation, especially using a vibrator Men: ejaculation, infection or inflammation of the testicles (epididymitis), or pressing or squeezing of the testicles Women: menstruation, pregnancy (especially labor and delivery), or infections of the vagina (vaginitis) or uterus (pelvic inflammatory disease) OTHER CAUSES Clots in the leg or pelvis veins (deep vein thrombosis) that may travel to the lungs (pulmonary emboli)* Broken bones or other injuries Everyday problems such as tootight clothing, shoes, appliances, or braces Extreme temperatures (too hot or too cold), or quick temperature changes

A GUIDE

FOR

HOW TO PREVENT IT

PEOPLE WITH SPINAL CORD INJURY

Be aware that these activities and conditions are possible causes of autonomic dysreflexia. You may want to discuss these issues with your health-care professional. If youre pregnant or planning a pregnancy, look for an obstetrician/gynecologist whos willing to work with you and with other health-care professionals who know your SCI care.

Recognize that all these problems can cause autonomic dysreflexia. Alert your health-care professionals and share this information with them. Make sure your clothes, shoes, appliances, and braces fit comfortably. Try to avoid extremes in temperature. Plan to dress appropriately.

* For more detailed information on deep vein thrombosis (thromboembolism), a complete Prevention of Thromboembolism clinical practice guideline is available at the website: www.pva.org or by calling toll-free (888) 860-7244.

gastritisInflammation of the stomach.

cystoscopyAn examination of the inside of the bladder and ureter. Its done with an instrument called a "cystoscope." epididymitisInflammation of the part of the testicle called the "epididymis."

autonomic nervesNerves in the spinal system that control involuntary action. bradycardiaSlow heart rate, usually fewer than 60 beats per minute.

Be sure to discuss your autonomic dysreflexia kit with your health-care professional. Ask if you should include other supplies. Also ask if your health-care professional can give you prescriptions for items in the kit.

Glossary

autonomic dysreflexiaAn abnormal response to a problem in the body below a spinal cord injury. Its most likely to happen if the SCI is at or above the 6th thoracic vertebra (T-6).

and in the back pocket of this Guide.)

barium enemaAn examination of the inside of the body done with a substance called "barium." This test is also called a "double-contrast examination." deep vein thrombosisClots in the leg or pelvis veins. Also referred to as thromboembolism.

pulmonary emboliBlood clots that travel to the lungs.

sigmoidoscopyAn examination of the part of the colon called the "sigmoid

pelvic inflammatory disease (PID)An infection anywhere in a womans genital tract above the cervix.

impaction (of the bowel)Occurs when hard stool is stuck in the rectum or somewhere else in the bowel.

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My Personal Autonomic Dysreflexia Diary

This Personal Diary is intended for you to use to keep a health-care record of your episodes of autonomic dysreflexia. Another copy of the Diary, which you can photocopy for re-use, appears in the back pocket of this Guide. Keep this diary and the Guide with you.

Name: City

Address:

Symptoms

Put a checkmark or "X" next to every symptom you have for each dysreflexia episode.

Date of Dysreflexia Episode:

Phone Number: (

Social Security Number:

State:

Date of Birth: Tight chest

Zip Code:

Cause of Dysreflexia Episode and Comments:

Seeing spots Stuffy nose

Flushed skin

Anxiety or jitters

Blurry vision

Heavy sweating Goose bumps

Pounding headache

Other:

Trouble breathing

11

Date of Dysreflexia Episode:

Symptoms

Put a checkmark or "X" next to every symptom you have for each dysreflexia episode.

Goose bumps Seeing spots Stuffy nose Blurry vision

Pounding headache Flushed skin Heavy sweating

Cause of Dysreflexia Episode and Comments: Date of Dysreflexia Episode:

Anxiety or jitters

Other:

Trouble breathing

Tight chest

Symptoms

Put a checkmark or "X" next to every symptom you have for each dysreflexia episode.

Goose bumps Seeing spots Stuffy nose Blurry vision

Pounding headache Flushed skin Heavy sweating

Cause of Dysreflexia Episode and Comments:

Anxiety or jitters

Other:

Trouble breathing

Tight chest

12

Symptoms

Put a checkmark or "X" next to every symptom you have for each dysreflexia episode.

Date of Dysreflexia Episode:

Cause of Dysreflexia Episode and Comments:

Stuffy nose

Heavy sweating Goose bumps Seeing spots Blurry vision Flushed skin

Pounding headache

Anxiety or jitters

Other:

Tight chest

Trouble breathing

Symptoms

Put a checkmark or "X" next to every symptom you have for each dysreflexia episode.

Date of Dysreflexia Episode:

Cause of Dysreflexia Episode and Comments:

Stuffy nose

Heavy sweating Goose bumps Seeing spots Blurry vision Flushed skin

Pounding headache

Anxiety or jitters

Other:

Tight chest

Trouble breathing

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MEDICAL HISTORY
Date of Spinal Cord Injury: Blood Type:

Normal Blood Pressure: Phone Number: Medications: Relationship:

Primary Health-care Professional:

Neurologic Location of Injury:

EMERGENCY INFORMATION

In Case of Emergency, Call: Phone Number: ( Group Number: )

INSURANCE INFORMATION

Name of Insurance Company: Identification Number: Phone Number: ( Plan Subscriber: )

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