Nassau County Seal
Nassau County Department of Health
Nassau County Resident Request Form for
COVID-19 Isolation/Quarantine Order
Mailing Address:
I acknowledge and consent as follows:

  • I am responsible for providing correct and accurate information on this Form, including full name, date of birth, email address, mailing address, and phone number and all responses on this form.

  • 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 (HIPAA) for transmission of protected information.

  • I authorize Nassau County Department of Health to transmit my personal health information (Response to Request for COVID-19 Isolation/Quarantine Order) via email.
I agree to E-Mail/Electronic Communication Consent above:
If you answer no your response to the request will be mailed to you.
Applicant Verification Statement
  • By signing below, I attest that the information I have provided in this Request Form (“application”) is true, accurate and complete to the best of my knowledge. This Form is a legal governmental instrument, and submission of false information may be grounds for disapproval of your application, and may subject you to criminal penalties under the New York State Penal Law.
  • I understand that if I do not sign the applicant verification statement that this request will not be processed.
If you choose to apply for COVID-19 isolation/quarantine order using a written application instead of this electronic request please click the print button below and send the completed written form to Nassau County Department of Health, 200 County Seat Drive, Mineola NY 11501. Attn.: Office of Public Health Legal Affairs. You will receive a written response from Nassau County Department of Health if you submit a written request.