Healthcare Exemption Certification

HEALTHCARE EXEMPTION CERTIFICATION

Purpose: Use this form to request a medical exemption from a specified healthcare requirement. Complete all applicable sections and attach supporting clinical documentation. Incomplete forms may result in denial of the exemption request.

Patient Information

Date of birth:    Gender: Male Female Other Decline to state

Emergency Contact

Insurance Information

Exemption Requested

Select one or more exemption categories and provide specific details as applicable.

Medical exemption from immunization — specify vaccine(s):

Medical exemption from specific treatment/procedure — specify:

Mask or personal protective equipment exemption — rationale:

Other exemption (describe):

Medical Basis and Supporting Information

Date condition first identified:    Anticipated duration of exemption:

Supporting documentation attached: Medical records Laboratory reports Clinician note Other

Attending Clinician Information (if applicable)

Clinician attests that the information above is accurate and reflects the clinician's medical judgment:

HIPAA / Release Authorization

I authorize release of medical information necessary to evaluate this exemption request, including but not limited to relevant medical records, test results, and clinician notes. I understand that records released pursuant to this authorization may be used only for the purpose of evaluating the exemption request and may be retained by the recipient for recordkeeping consistent with applicable law.

Authorization to release records: Yes    No

Certification and Acknowledgment

By signing below, I certify under penalty of law that the information provided on this Healthcare Exemption Certification is true and complete to the best of my knowledge. I understand that knowingly providing false information in support of an exemption request may subject me to civil or administrative penalties under applicable statutes and regulations.

I understand that approval of this exemption request is discretionary and may require review of supporting medical documentation. I consent to release of such documentation to the entity reviewing this request and acknowledge that additional information may be requested to substantiate the exemption.

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