Nassau County, NY

Nassau County Department of Health

Nassau County Resident Request Form for
COVID-19 Isolation/Quarantine Order

First Name:

Last Name:

Date of Birth (mm/dd/yyyy):

Email Address:

Verify Email Address:

The email addresses you entered do not match!

Mailing Address:

Address:

Address Apt# (If applicable)

City:

State:

Zip code:

Phone Number Where You Can Be Reached:

I was placed under Isolation, Quarantine and Restriction because (choose one):

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:

Yes

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.

Name:

Signature:

Date (mm/dd/yyyy):

The name and signature field you entered do not match!

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.

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.

Please fill in all fields with an *

Nassau County Department of Health

Nassau County Resident Request Form for
COVID-19 Isolation/Quarantine Order

Attach documents of proof (.pdf, .jpeg, .jpg, .png, .gif)

Attach documents of proof (.pdf, .jpeg, .jpg, .png, .gif)

You must provide details such as symptoms, date, who sent you home:

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

Applicant Verification Statement

Nassau County Department of Health

Nassau County Resident Request Form for COVID-19 Isolation/Quarantine Order

Attach documents of proof (.pdf, .jpeg, .jpg, .png, .gif)

Attach documents of proof (.pdf, .jpeg, .jpg, .png, .gif)

You must provide details such as symptoms, date, who sent you home:

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

Applicant Verification Statement

Nassau County Resident Request Form for
COVID-19 Isolation/Quarantine Order