Healthcare County Report

HEALTHCARE COUNTY REPORT

Report Identification

County Name:   Report ID:

Date of Report: Month Day Year

Reporting Facility and Reporter

Title:   License/ID:   Contact Phone:

Patient Demographics

Date of Birth:   Gender: Male Female Other

Patient Phone:   Alternate Phone:

Insurance Information

Policy Number:   Group Number:   Subscriber Name:

Medical History (Relevant)

Clinical and Laboratory Information

Primary Diagnosis:   ICD / Code:

Date of Onset: Month Day Year

Date of Diagnosis: Month Day Year

Fever Cough Shortness of Breath Chills Diarrhea

Specimen Type:   Test Performed:

Test Result:   Specimen Collected: Month Day Year

Treatment and Disposition

Was the patient admitted? Yes No

Admission Date: Month Day Year

Discharge Date: Month Day Year

Recovered Ongoing care Deceased

Vaccination and Exposure

Vaccinated for Relevant Agent? Yes No

Recent travel Animal contact Occupational exposure Household contact

Public Health Actions Requested

Contact tracing requested Isolation / Quarantine recommended Other

Authorization and Confidentiality

Authority and Purpose: Under applicable public health law, this information is collected for surveillance, control, and prevention of disease. Information provided will be used by authorized county public health personnel to investigate, manage exposure risks, and implement control measures necessary to protect public health.

Confidentiality: Records submitted to the county are maintained as confidential health information and will be disclosed only as permitted by law to authorized public health entities, laboratories, or care providers for public health purposes. Unauthorized disclosure is prohibited and subject to legal restrictions.

I authorize my healthcare provider to disclose my protected health information, including diagnosis, laboratory results, hospitalization status, and other relevant clinical information, to county public health authorities for public health surveillance, investigation, and control measures. I understand that this information may be used to locate and notify persons who may have been exposed.

Expiration: This authorization expires on unless earlier revoked in writing. I understand I may revoke this authorization at any time by submitting written notice, except to the extent that action has already been taken in reliance on this authorization.

Certification: I certify that the information provided on this Healthcare County Report is true and complete to the best of my knowledge. I understand that knowingly making a false statement may be subject to penalties under law.

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