Healthcare Shielding Document

Healthcare Shielding Document

Facility Name:   Date Submitted:

Patient Information

Emergency Contact

Insurance Information

Medical History

Shielding Request & Measures

I request the following shielding measures be implemented to reduce my exposure to transmissible agents while receiving care. Select all measures requested and provide supporting detail where indicated.

Private room isolation (single-occupancy)

Assignment of dedicated clinical staff when feasible

Require personal protective equipment for visitors and staff entering room

Visitor limitation or scheduled visitation only

Use of telehealth consultations where clinically appropriate

Contactless medication and supply delivery

Risks, Benefits, and Acknowledgments

I acknowledge that the requested shielding measures are intended to reduce infection risk but may involve limitations, including restricted visitation, changes in routine care delivery, potential transfer to alternate care areas, and impacts to social support. I understand that facility staff will evaluate clinical appropriateness and resource availability before implementing measures.

I acknowledge that, when shielding measures are implemented, clinical staff will take reasonable precautions consistent with facility policy and professional standards. I further acknowledge that no measure can guarantee absolute protection from exposure and that emergency care may require deviation from shielding protocols to preserve life or safety.

By signing below I confirm that I have read and understand the foregoing statements, and I consent to the implementation of the shielding measures that are determined to be medically appropriate and administratively feasible.

I acknowledge and understand the risks, benefits, and limitations described above.

Authorization to Share Limited Information

I authorize the facility to disclose limited health information to personnel, contractors, and designated contacts as needed to implement shielding measures. Disclosure is limited to information necessary for care coordination and infection control (for example: isolation status, required precautions, scheduling restrictions).

I understand that I may revoke this authorization at any time by submitting a written revocation to facility administration; revocation will not affect disclosures already made in reliance on this authorization prior to the facility's receipt of the revocation.

Certification and Release

I certify that the information I have provided on this Healthcare Shielding Document is true and complete to the best of my knowledge. I consent to the facility's reasonable implementation of shielding measures as described. I further acknowledge that the facility will act in accordance with applicable standards of care; to the extent permitted by law, I agree not to hold the facility liable for adverse outcomes directly resulting from necessary clinical interventions or public health directives, except for gross negligence or willful misconduct.

I authorize clinical staff to take reasonable steps necessary to implement shielding, including but not limited to communication with other providers, scheduling changes, or temporary transfer to alternative care locations. I understand that the facility will document shielding decisions in my medical record.

If this form is signed by a legal guardian or authorized representative, I certify that I have the legal authority to act on behalf of the patient and will provide documentation of that authority upon request.

I certify the above information is accurate and I consent to the requested shielding measures subject to clinical assessment and facility policy.

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