Healthcare Covid Guidelines

HEALTHCARE COVID GUIDELINES — PATIENT ACKNOWLEDGMENT

Purpose: These Healthcare COVID Guidelines set forth facility infection-prevention requirements, patient screening protocols, and behavioral expectations to reduce transmission of SARS-CoV-2 within clinical settings. By signing below, the patient or authorized representative certifies that the information provided is true and agrees to comply with the facility's infection-control measures while on premises.

Patient Information

Insurance Information

Medical Screening — Symptoms and Exposure

Within the past 14 days, check any current symptoms or exposures you have experienced. If any box is checked, additional instructions may apply.

Exposure: Have you had close contact with a confirmed or suspected COVID-19 case within the past 14 days? Yes No

Vaccination and Testing Status

Vaccination status (check appropriate box and provide date of last dose).

Facility Infection-Control Requirements

While present in the facility, patients and visitors must comply with the following measures. The facility retains the right to deny entry or require removal from premises for noncompliance.

• Masking: All individuals must wear an approved face covering over nose and mouth in clinical areas when directed by staff. Staff may require a medical-grade mask.
• Screening: Patients may be required to undergo point-of-care symptom screening and temperature checks before appointments or procedures.
• Testing: For certain visits or procedures, pre-visit testing for SARS-CoV-2 may be required; failure to complete required testing may result in rescheduling.
• Isolation/Quarantine: Individuals with confirmed infection or high-risk exposure must follow current public health isolation/quarantine guidance provided by the facility.

Acknowledgement: I understand and agree to adhere to the infection-control requirements listed above and to notify the facility promptly of any new symptoms or exposures prior to arrival.

Patient Rights and Provider Responsibilities

The patient retains the right to ask questions, refuse or withdraw consent for specific procedures, and request reasonable accommodations. The facility will make reasonable efforts to provide safe care and to explain alternatives if infection-control measures affect scheduling or access to services.

Warning: Intentionally providing false or misleading information regarding symptoms, exposures, or vaccination/testing status may result in denial of services and may subject the signer to civil or criminal penalties under applicable laws governing false statements to healthcare providers.

Privacy and HIPAA Acknowledgement

The facility maintains privacy protections for your health information. Limited disclosures of COVID-19 related health information may be made to public health authorities or other entities as permitted by law. By signing, you acknowledge receipt of privacy information and authorize the facility to collect and use screening and test results for care coordination and required public health reporting.

Authorization and Expiration

This acknowledgement authorizes the facility to apply the stated infection-control measures to the signer and is effective immediately upon signature. This acknowledgement will remain in effect until the earlier of patient discharge from active treatment or the expiration date noted below.

Additional Medical Information

Declarations and Signature

I hereby declare under penalty of perjury that the information I have provided in this Healthcare COVID Guidelines acknowledgement and screening form is true and correct to the best of my knowledge. I understand the facility's infection-control requirements and consent to comply while receiving care. I have received the privacy information described above.

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