NASSAU COUNTY DEPARTMENT OF HEALTH
200 COUNTY SEAT DRIVE
MINEOLA, NY, 11501
NASSAU COUNTY RESIDENT REQUEST FORM FOR
COVID-19 RELEASE FROM HOME ISOLATION/QUARANTINE ORDER
I am seeking a Release letter because:*
Applicant Verification Statement
  • By signing the below, I swear or affirm that the information in this Request Form ("application") is accurate, true and complete to the best of my knowledge. I understand that if I have knowingly made a false statement herin, I may be subject to prosecution under New York State Penal Law 210.45. Further, submission of a false statement is grounds for disapproval of this application.
  • I am responsible for providing all correct information including full name, date of birth, email address, mailing address, and phone number on this form.
  • I understand that if I receive a Letter of Release from Isolation or Quarantine, this only releases from medical isolation or quarantine imposed by the Nassau County Department of Health and does not release from any other restrictions related to COVID-19 imposed by the State of New York.
  • I understand that pursuant to the Electronic Signatures and Records Act (ESRA), the use of an electronic signature shall have the same validity and effect as a signature by hand.