Healthcare COVID-19 Policy

HEALTHCARE COVID-19 POLICY

Patient Information

Insurance Information

Medical History

Policy Purpose, Scope, and Definitions

Purpose: This Healthcare COVID-19 Policy sets forth requirements and expectations for patients, visitors, and staff of the clinic in order to minimize transmission of SARS-CoV-2 within the facility while preserving access to medically necessary services.

Scope: This policy applies to all persons present on premises for clinical care, administrative business, or visitation. The clinic may apply additional infection-control measures as required by public health authorities.

Screening, Testing, and Reporting

Screening: All patients will be screened for symptoms of COVID-19 and recent exposure prior to entry. If you develop symptoms within 14 days of a visit, you must notify the clinic immediately and follow instructions for testing and isolation.

Testing consent: I consent to COVID-19 testing if clinically indicated or required by the clinic for safe delivery of care.

Temperature and symptom checks: I consent to temperature screening and symptom questionnaires at clinic entry.

Vaccination, Masking, and Source Control

Vaccination status (select all that apply):
Vaccinated Received booster Not vaccinated

Masking: Patients and visitors must comply with clinic masking requirements. The clinic will provide acceptable face coverings if required by clinic policy or public health order.

Isolation, Quarantine, and Patient Responsibilities

Isolation and quarantine protocols will be implemented for patients who test positive for COVID-19 or report exposure. Patients must follow instructions for self-isolation, follow-up testing, and medical care.

Patient responsibilities include promptly reporting symptoms or exposures, complying with screening and testing requests, and adhering to infection-control measures while on premises.

Visitor Policy and Telehealth

Visitors may be limited to support essential to care. The clinic may require remote participation or limit visitor presence for infection control. Telehealth alternatives will be offered when appropriate.

Reporting, Contact Tracing, and Data Use

The clinic will report confirmed cases and exposures to public health authorities when required by law. Patient contact information and limited clinical data may be disclosed to public health agencies for contact tracing and outbreak control.

I consent to the clinic sharing my contact information and relevant clinical information with public health authorities for the purpose of reporting and contact tracing, to the extent required by law.

Confidentiality and Legal Exceptions

The clinic will maintain confidentiality of health information in accordance with applicable privacy laws. Notwithstanding confidentiality obligations, the clinic may disclose protected health information without patient authorization when required by public health law, court order, or other legal process.

Acknowledgement, Consent, and Rights

By signing below I acknowledge that I have read, understand, and will comply with the clinic's COVID-19 Policy. I understand that refusal to comply may result in delay or limitation of services when necessary to protect health and safety.

Right to withdraw: I understand I may withdraw any consents in writing, but withdrawal will not affect uses or disclosures already made in reliance on this consent nor actions taken to protect public health.

Authorization Period

Effective date:     Authorization expiration date:

HIPAA / Privacy Acknowledgement

I acknowledge that I have been provided with the clinic's Notice of Privacy Practices regarding use and disclosure of my protected health information as it relates to COVID-19 screening, testing, reporting, and contact tracing.

Additional Patient Declarations

I declare under penalty of law that the information I have provided in this form is true and correct to the best of my knowledge.

Notes (Clinic use)

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