Healthcare Masking Guidelines

HEALTHCARE MASKING GUIDELINES

Patient Information

Date of Birth: Gender:

Insurance Information

Medical History Relevant to Masking

Do you have a breathing or cognitive condition that prevents mask use? Yes No

If yes, briefly describe diagnosis and functional limitation:

Masking Requirements and Scope

Purpose: These Guidelines establish the facility's requirements for face coverings while on premises, including patient care areas, waiting rooms, clinical corridors, and administrative spaces. All persons entering the facility must comply with masking rules except as provided below. The facility retains discretion to require masking regardless of vaccination status when clinical risk is present.

Acceptable face coverings (select all that apply): Surgical mask N95 / P100 respirator (fit-tested for staff) KN95 Multi-layer cloth mask (recommended) Face shield alone is NOT acceptable

The facility may provide a compliant mask upon entry when an individual arrives without one. Refusal to wear a provided mask when required may result in denial of non-emergency services or removal from premises.

Exemptions and Accommodation Procedure

Medical Exemption: A medical exemption from mask use may be granted when a documented medical condition prevents safe mask wearing. Requests must be supported by clinical documentation submitted to the facility's Patient Access or Disability Services. Provision of documentation does not automatically guarantee exemption; the facility will engage in an individualized assessment.

When an exemption is approved, the accommodation will be time-limited and documented. Exemption expiration date:

Alternative measures for individuals granted exemption may include remote visits, physical distancing, scheduling adjustments, or use of barriers. The facility will seek to provide reasonable accommodations consistent with patient and staff safety.

Responsibilities and Enforcement

Patient and Visitor Responsibilities: Patients and visitors shall comply with masking requirements while on campus unless a valid accommodation has been issued. Compliance contributes to infection prevention for all facility occupants.

Staff Responsibilities: Staff must wear facility-approved masks in clinical and public areas and must follow procedures for screening, offering masks, documenting accommodation requests, and escalating noncompliance to supervisory personnel.

Enforcement: Refusal to comply with masking requirements may lead to postponement of elective services, discharge from care areas for non-safety-critical visits, or other actions necessary to protect patients and staff.

Privacy and Use of Medical Information

Medical information provided in support of an accommodation request will be used solely for the assessment and administration of the accommodation and will be maintained in the patient's medical record or disability services record in accordance with applicable privacy protections. Only staff with a need to know will access supporting documentation.

By signing below, the patient or authorized guardian consents to the use of submitted clinical information for the purpose of evaluating masking exemptions and accommodations.

Acknowledgment: I acknowledge that I have received, read, and understand these Healthcare Masking Guidelines. I understand the facility's right to require masking to protect patient and staff safety, the process for requesting accommodations, and that false statements or falsified documentation may result in denial of exemption and other actions.

I acknowledge the privacy and use provisions above.

Sign Now