Healthcare COVID Document

HEALTHCARE COVID DOCUMENT

Patient Information

Date of birth:    Gender:    Patient ID (if applicable):

Emergency Contact

Insurance Information

Policy number:    Group number:

Medical History and Risk Factors

Are you currently pregnant? Yes    Are you immunocompromised? Yes

COVID-19 Screening Questions (within past 14 days)

Fever (temperature >100.4°F): Yes No

New cough or shortness of breath: Yes No

New loss of taste or smell: Yes No

Close contact with confirmed COVID-19 case: Yes No

Travel outside local area in last 14 days: Yes No

Testing / Vaccination Consent

Procedure requested (check applicable and specify details): COVID-19 Test    COVID-19 Vaccination

I authorize the provider to perform the indicated procedure. I understand the procedure involves specimen collection or vaccine administration and may result in temporary discomfort. I acknowledge the following risks (including but not limited to): injection site pain, redness, swelling, transient fever, allergic reaction, fainting, and, rarely, severe adverse events. For tests, I understand false negative and false positive results are possible and test results do not guarantee absence or presence of infection.

Benefits: identification of active infection to permit timely treatment and public health actions; for vaccination, reduction in risk of severe disease. Alternatives: decline testing or vaccination. I understand I may withdraw consent at any time prior to specimen collection or vaccine administration without affecting other medical care.

Authorization to Release Results and Information

I authorize release of my COVID-19 test results and vaccination status to: health care providers, public health authorities as required by law, and my employer if necessary for workplace health and safety. List any additional persons or entities authorized to receive results:

This authorization is valid until: . If no date is entered, the authorization will remain in effect for one year from the date of signature, except where a shorter period is required by law.

HIPAA Privacy Acknowledgment

By signing below I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my health information may be used and disclosed and my rights under applicable privacy laws. I understand my protected health information related to COVID-19 testing and vaccination may be disclosed consistent with public health reporting requirements.

I acknowledge: I acknowledge receipt of privacy information and understand my rights.

Certification and Attestation

I certify under penalty of perjury that the information I have provided on this form is true and correct to the best of my knowledge. I understand falsification of material information may have legal or administrative consequences and may affect clinical decisions. I consent to the procedures identified above and authorize the release of relevant medical information as described.

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