DAL 17-03 - Identification of Unidentified Patients - Model Policy

January 5, 2017


Dear Chief Executive Officer:

The New York State Missing Persons Clearinghouse (MPC) has partnered with the New York State Department of Health (DOH) to provide hospital administrators with an Identification of Unidentified Patients – Model Policy.

The Clearinghouse is located at the New York State Division of Criminal Justice Services (DCJS). The Clearinghouse's statutory obligations and responsibilities are set forth in New York State Executive Law Sections 837, 837- e, 837-f, 837-f-1, and 838; Education Law sections 355, 6206, 6303, and 6450; and Part 6055 of Title 9 of New York State Codes, Rules and Regulations.

The MPC is responsible for providing support to law enforcement agencies handling cases involving children, college students, and vulnerable adults who have gone missing. A critical part of the Clearinghouse mission is coordinating three distinct statewide notifications similar in function to AMBER Alerts.

  1. Missing Child Alert: Activated when a child under the age of 21 is missing and he or she is believed to be in danger due to special circumstances, such as a mental impairment or medical condition that places them at risk. Such an alert is often activated when a disappearance does not meet the threshold of a state AMBER Alert.
  2. Missing College Student Alert: Activated when a college student of any age is missing and is deemed to be at credible risk of bodily harm or death.
  3. Missing Vulnerable Adult Alert: Activated when an individual 18 or older with Alzheimer's, dementia, autism or other cognitive disorder, brain injury or mental disability is reported missing and is at credible risk of harm.

In the course of administering the Missing Vulnerable Adult Alert program, MPC staff became aware of several instances of a missing adult with Alzheimer's disease who was admitted to a hospital as an unidentified patient and police and family members were unable to locate the individual. After further investigation, the MPC discovered that there is not an existing standardized protocol among hospitals when admitting an unidentified patient. The inconsistent nature of assigning a temporary name to an unidentified patient and the interaction with law enforcement and family members leads to further traumatizing a family who is searching for a missing loved one. For example, early in 2016 an elderly gentleman who has Alzheimer's disease was admitted to a hospital through the emergency department as an unknown patient. He was assigned the name "Trauma XXX". Although law enforcement and family members inquired at the hospital several times, they were told the man was not a patient at the hospital. Hundreds of family members, friends and law enforcement personnel continued their search for the man over the period of a week until finally a doctor at the facility saw a news story on television about the missing man and recognized him as "Trauma XXX." When the man's son asked the hospital why they were unable to connect that his missing father, who had been at the hospital since the day he went missing, was the man law enforcement and the family had inquired about, he was told because they did not ask if anyone was admitted under the name of "Trauma XXX."

As a result, the MPC and DOH convened a panel of experts to develop an Identification of Unknown Patients – Model Policy. Representatives from Albany Medical Center, Albany Memorial Hospital, Greater New York Hospital Association, New York Division of Criminal Justice Services, New York State Office of Alcoholism and Substance Abuse Services, New York State Office of Mental Health and the Samuel Stratton VA Medical Center came together to provide their expertise in the development of the policy.

The goal of the policy is two-fold: to provide hospital administrators with a consistent protocol throughout New York State when admitting an unidentified patient into a hospital and to have a standardized process of reacting to requests for information from police and family members of missing persons.

Key components of the model include:

  • Citations of both federal and state laws that allow for disclosures to law enforcement when dealing with a missing/unidentified person case;
  • Definitions of key terms used in the policy and that are helpful when implementing the protocol;
  • A generalized procedure for hospital record keeping and the temporary naming of the unidentified patient.
  • Guidance on steps to take to identify the patient, and;
  • Administrative action to be taken after the patient is identified.

We hope that this model policy will provide you with a basic protocol that can be easily implemented at your facility and that this standardized process will lessen the trauma and anxiety a family faces when searching for a missing loved one and allow for the identification of an unknown patient in a more reasonable time frame.

Please contact the Department of Health or the Clearinghouse with any questions or concerns.

  • NYS Missing Persons Clearinghouse
    Division of Criminal Justice Services
    80 South Swan Street
    Albany, NY 12210

Thank you.


Ruth Leslie
Division of Hospitals and Diagnostic & Treatment Centers

Johanna Sullivan
Office of Public Safety
Division of Criminal Justice Services