Monroe County, NY COVID-19 Release Request Form

* Required Fields

Prefix

First Name *

M.I.

Last Name *

Suffix

Date of Birth *

Did you test positive for COVID-19? * Yes No

Your Email *

Phone *

Alternate Phone

Street Address - Line 1 *

Address - Line 2

City *

State *

Zip *

I certify that it has been at least ten (10) days, or fourteen (14) days if I was hospitalized, since I first began experiencing any of the following symptoms: fever, cough, shortness of breath or other respiratory distress.

I certify that I have not had a fever in at least twenty four hours (24) and have not taken any fever-reducing medication (such as Tylenol) in that same period of time.

I certify that any respiratory issues I have suffered have improved.

By certifying the answers above, I swear or affirm that the answers I have provided above are true to the best of my knowledge. I understand that if I have knowingly made a false statement herein, I may be subject to prosecution under N.Y. Penal Law Pursuant 210.45. You Certify this is True.

I consent to electonic delivery of a release from isolation or quarantine letter from the Monroe County Department of Health. I understand that the letter will reference COVID-19, and contain personally identifiable information as that is defined under the health insurance portability and accountability act (HIPAA). I also understand that electronic mail is not a secure form of communication. By selecting Yes, I release the county of Monroe from any liability that might arise from transmission of a release letter through electronic means to the email address listed above.

I UNDERSTAND THAT IF I RECEIVE A RELEASE LETTER, THIS ONLY RELEASES ME FROM MEDICAL ISOLATION OR QUARANTINE IMPOSED BY THE MONROE COUNTY DEPARTMENT OF HEALTH, AND DOES NOT RELEASE ME FROM ANY OTHER RESTRICTIONS RELATED TO COVID-19 IMPOSED BY THE STATE OF NEW YORK. I CERTIFY I UNDERSTAND.