Healthcare Visitation Packet

HEALTHCARE VISITATION PACKET

FACILITY & PATIENT IDENTIFICATION

Facility Name:

Date of Birth:    Gender:

Phone:    Room/Unit:

EMERGENCY & PRIMARY CONTACT

Relationship:    Phone:

VISITOR DESIGNATION & AUTHORIZATION

The undersigned patient (or authorized representative) designates the following persons authorized to visit and receive health information while the patient is under the care of the facility. Authorized visitors may be added or removed by written notice to facility staff.

Special restrictions or exceptions to visitation (e.g., no children, restricted hours, clinical limitations):

Authorization Expiration Date:

INFECTION CONTROL & SCREENING

All visitors must comply with facility infection prevention measures. Any visitor presenting symptoms or exposure risks may be denied entry. Please answer the following for each visitor prior to each visit. If any item is checked, entry may be restricted until cleared by clinical staff.

Fever or chills     New cough     Shortness of breath or difficulty breathing

Sore throat     Nausea, vomiting or diarrhea     New loss of taste or smell

Within the past 14 days, any close contact with a person diagnosed with a communicable respiratory illness or any international travel?   Yes    No

Visitor has received vaccinations recommended for the patient's condition or outbreak-specific vaccines (if required by facility):   Yes    No

PATIENT CONSENT & AUTHORIZATIONS

I, the undersigned patient or authorized representative, authorize the facility to allow the persons listed in this packet to visit me and to receive information about my condition as permitted under applicable privacy laws. This authorization includes oral disclosures to authorized visitors regarding my diagnosis, condition, and care needs as necessary to facilitate visitation and safety.

I understand that:

• Visitation may be limited, modified, or revoked at any time to protect patient safety, clinical care, or infection control.
• Facility staff may require visitors to undergo temperature checks, symptom screening, or wear personal protective equipment (PPE) as directed.
• I may revoke this authorization at any time by notifying facility staff in writing; revocation is not effective to the extent the facility has already acted in reliance on this authorization.

By signing below, I acknowledge that I have read and understand the visitor obligations contained herein and authorize disclosure of my health information to the authorized visitors to the extent necessary to facilitate visitation.

VISITOR RESPONSIBILITIES & LIABILITY

Authorized visitors agree to abide by all facility policies while on premises, including but not limited to infection control procedures, visiting hours, movement restrictions, and respect for patient privacy and confidentiality. Visitors who fail to comply may be removed and may have visitation privileges revoked.

The facility is not liable for personal property brought by visitors. Visitors accept responsibility for their conduct and any harm resulting from failure to follow facility instructions.

CONFIDENTIALITY & HIPAA ACKNOWLEDGMENT

I acknowledge that information disclosed to authorized visitors may include protected health information. I understand the facility will limit disclosures to the minimum necessary to accommodate visitation and care coordination. I also acknowledge that authorized visitors will be instructed to preserve my privacy and confidentiality.

ACKNOWLEDGMENT & SIGNATURE

By signing below I affirm that the information provided in this visitation packet is accurate to the best of my knowledge and that I have authority to make the designations contained herein. I understand that my signature constitutes a legal authorization for visitation and disclosure as stated above, subject to facility policies and applicable law.

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