Healthcare COVID-19 Support Form

HEALTHCARE COVID-19 SUPPORT FORM

This form documents the request for COVID-19 related support services, the patient’s medical and exposure status, and the patient’s consent to receive and share information necessary to coordinate care and public health assistance. Completion of this form authorizes the named organization and its authorized agents to provide indicated services and to disclose relevant health information to third-party service providers and public health authorities where required by law or as necessary to provide services.

Patient Information

Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

COVID-19 Screening

Current symptoms (check all that apply):

Fever or chills Cough Shortness of breath Sore throat Loss of taste or smell

Nausea / Vomiting Diarrhea Headache None of the above

Symptom onset date:

Known exposure to confirmed or suspected COVID-19 case in last 14 days: Yes No

Testing and Vaccination

Have you been tested for COVID-19 for this illness episode? Yes No

Test type: PCR Antigen Other

Test result: Positive Negative Pending

COVID-19 Vaccination: Yes No

Support Services Requested

Please check all services you are requesting:

Home health visits Medication delivery Food delivery

Transportation to testing/medical appointments Telehealth / remote monitoring Isolation housing / temporary shelter

Consent for Assistance and Information Release

I authorize the organization named below and its contracted service providers to provide the requested COVID-19 related support services. I authorize my health information related to COVID-19, including screening, testing, vaccination status, and relevant medical history, to be disclosed to service providers, care coordinators, and public health authorities as necessary to arrange and deliver services. I understand that information disclosed pursuant to this authorization may include protected health information and that such disclosures will be limited to the minimum necessary to accomplish the stated purpose.

I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization if those disclosures were made prior to receipt of the revocation.

Acknowledgment and Certification

By signing below, I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I acknowledge that receipt of services is voluntary, that I may refuse any service, and that services provided may involve risks, including the risk of potential exposure to infectious agents. I agree to follow the instructions and conditions communicated by service providers to minimize risk.

I acknowledge that in emergency circumstances or where required by public health law, certain disclosures of my health information may be made without my authorization. I understand my rights to request amendments to my health record and to request restrictions on certain uses and disclosures as permitted by law.

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