DOH - COVID Release

NASSAU COUNTY DEPARTMENT OF HEALTH
200 COUNTY SEAT DRIVE
MINEOLA, NY, 11501

NASSAU COUNTY RESIDENT REQUEST FORM FOR
COVID-19 RELEASE FROM ISOLATION/QUARANTINE ORDER

First Name

Last Name

Date of Birth (mm/dd/yyyy)

Email Address

Confirm Email Address

Mailing address with apartment number

City

State

Zip Code

Phone number where you can be reached

I am seeking a Release letter because:*

I tested positive for COVID-19 and am in Isolation.

Date of Test or First Date of Symptoms(mm/dd/yyyy):

In order to qualify for a Release letter the date of test or first date of symptoms must have more than 10 days ago.

I swear or affirm that I am eligible for release from home isolation because I have met the following conditions:

IF SYMPTOMATIC

At least 3 days (72 hours) have passed since recovery, defined as resolution of fever without the use of fever-reducing medications; AND
My respiratory symptoms (e.g., cough, shortness of breath) have improved; AND
At least 10 days have passed since my symptoms first appeared.

IF ASYMPTOMATIC

At least 10 days have passed since the date of my COVID-19 diagnostic test; AND
I have had no subsequent illness.

Applicant E-Mail/Electronic Communication Consent for NCDOH to Respond to COVID-19 I&Q Order Request

I acknowledge and consent as follows:

I acknowledge that commonly used e-mail services are not secure and fall outside the security requirement set forth by the Health Insurance Portability and Accountability Act for the transmission of protected information.
I understand there is a risk that my health information may be obtained by others.
I release the County of Nassau from any liability that might arise from transmission of a Letter of Release from Isolation or Quarantine through electronic means to the email address I have provided.
I authorize Nassau County Department of Health to transmit my personal health information (Response to Request for COVID-19 Release from Isolation/Quarantine Order) via email even though email may not be secure and private and may be subject to loss or exposure.

My child (under 18 years old) tested positive for COVID-19 and is in Isolation.

Child's Name

Child's Date of Birth (mm/dd/yyyy)

Date of Test or First Date of Symptoms (mm/dd/yyyy):

In order to qualify for a Release letter the date of test or first date of symptoms must have been more than 10 days ago.

I swear or affirm that my child is eligible for release from home isolation because they have met the following conditions:

IF SYMPTOMATIC

At least 3 days (72 hours) have passed since my child 's recovery, defined as resolution of fever without the use of fever-reducing medications; AND
Their respiratory symptoms (e.g., cough, shortness of breath) have improved; AND
At least 10 days have passed since their symptoms first appeared.

IF ASYMPTOMATIC

At least 10 days have passed since the date of my child 's COVID-19 diagnostic test; AND
They have had no subsequent illness.

Applicant E-Mail/Electronic Communication Consent for NCDOH to Respond to COVID-19 I&Q Order Request

I acknowledge and consent as follows:

I acknowledge that commonly used e-mail services are not secure and fall outside the security requirement set forth by the Health Insurance Portability and Accountability Act for the transmission of protected information.
I understand there is a risk that the health information may be obtained by others.
I release the County of Nassau from any liability that might arise from transmission of a Letter of Release from Isolation or Quarantine through electronic means to the email address I have provided.
I authorize Nassau County Department of Health to transmit my child's personal health information (Response to Request for COVID-19 Release from Isolation/Quarantine Order) via email even though email may not be secure and private and may be subject to loss or exposure.

I was in close or proximate contact to an individual who tested positive for COVID-19 and am in Quarantine.

Date of Contact (mm/dd/yyyy):

In order to qualify for a Release letter the contact must have been more than 10 days ago.

I swear or affirm that I am eligible for release from home isolation because I have met the following conditions:

I have had no symptoms (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) during the quarantine period.
I agree to continue daily symptom monitoring for Fourteen (14) Days from the last date of close contact with a confirmed or suspect COVID-19 case; AND
I agree to continue strict hand hygiene and the use of face coverings through Day 14; AND
I agree that if I develop any symptoms, I will immediately self-isolate and contact my healthcare provider to report this change and determine if I should seek COVID-19 testing.

Applicant E-Mail/Electronic Communication Consent for NCDOH to Respond to COVID-19 I&Q Order Request

I acknowledge and consent as follows:

I acknowledge that commonly used e-mail services are not secure and fall outside the security requirement set forth by the Health Insurance Portability and Accountability Act for the transmission of protected information.
I understand there is a risk that my health information may be obtained by others.
I release the County of Nassau from any liability that might arise from transmission of a Letter of Release from Isolation or Quarantine through electronic means to the email address I have provided.
I authorize Nassau County Department of Health to transmit my personal health information (Response to Request for COVID-19 Release from Isolation/Quarantine Order) via email even though email may not be secure and private and may be subject to loss or exposure.

My child (under 18 years old) was in close or proximate contact to an individual who tested positive for COVID-19 and is in Quarantine.

Child's Name

Child's Date of Birth (mm/dd/yyyy)

Date of Contact (mm/dd/yyyy):

In order to qualify for a Release letter the contact must have been more than 10 days ago.

I swear or affirm that my child is eligible for release from home isolation because they have met the following conditions:

My child has had no symptoms (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) during the quarantine period.
I agree to continue daily symptom monitoring of my child for Fourteen (14) Days from the last date of close contact with a confirmed or suspect COVID-19 case; AND
I agree to continue to monitor my child 's strict hand hygiene and the use of face coverings through Day 14; AND
I agree that if my child develops any symptoms, I will immediately isolate my child and contact my healthcare provider to report this change and determine if I should seek COVID-19 testing for my child .

Applicant E-Mail/Electronic Communication Consent for NCDOH to Respond to COVID-19 I&Q Order Request

I acknowledge and consent as follows:

I acknowledge that commonly used e-mail services are not secure and fall outside the security requirement set forth by the Health Insurance Portability and Accountability Act for the transmission of protected information.
I understand there is a risk that the health information may be obtained by others.
I release the County of Nassau from any liability that might arise from transmission of a Letter of Release from Isolation or Quarantine through electronic means to the email address I have provided.
I authorize Nassau County Department of Health to transmit my child's personal health information (Response to Request for COVID-19 Release from Isolation/Quarantine Order) via email even though email may not be secure and private and may be subject to loss or exposure.

I agree to E-Mail/Electronic Communication Consent Above:

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.

Completed by

Signature

Date

NASSAU COUNTY DEPARTMENT OF HEALTH 200 COUNTY SEAT DRIVE MINEOLA, NY, 11501

NASSAU COUNTY RESIDENT REQUEST FORM FOR COVID-19 RELEASE FROM ISOLATION/QUARANTINE ORDER

I am seeking a Release letter because:*

I tested positive for COVID-19 and am in Isolation.

Applicant E-Mail/Electronic Communication Consent for NCDOH to Respond to COVID-19 I&Q Order Request

My child (under 18 years old) tested positive for COVID-19 and is in Isolation.

Applicant E-Mail/Electronic Communication Consent for NCDOH to Respond to COVID-19 I&Q Order Request

I was in close or proximate contact to an individual who tested positive for COVID-19 and am in Quarantine.

Applicant E-Mail/Electronic Communication Consent for NCDOH to Respond to COVID-19 I&Q Order Request

My child (under 18 years old) was in close or proximate contact to an individual who tested positive for COVID-19 and is in Quarantine.

Applicant E-Mail/Electronic Communication Consent for NCDOH to Respond to COVID-19 I&Q Order Request

Applicant Verification Statement

NASSAU COUNTY DEPARTMENT OF HEALTH
200 COUNTY SEAT DRIVE
MINEOLA, NY, 11501

NASSAU COUNTY RESIDENT REQUEST FORM FOR
COVID-19 RELEASE FROM ISOLATION/QUARANTINE ORDER