Rockland County DOH - Release Letter Request

UNABLE TO CONTINUE

This application is intended for Rockland County Residents only.

NOTE: You must be a resident of Rockland County, and you must have been ordered to isolate or quarantine by the Commissioner or her staff at Rockland County Department of Health (and not your medical provider or employer), in order to obtain the release letter or Commissioner’s Order.

COVID-19 Testing
Have you tested positive for COVID-19, or has a medical provider diagnosed you with COVID-19 based on your symptoms? *

Yes No

Adult Care Employee
Are you an employee at a Nursing Home, Adult Care Facility, Group Home or other Assisted Living Facility? *

Yes No

CONTACT DEPARMENT OF HEALTH

Based on your responses you must speak with a representative of the Rockland County Department of Health in order to receive your Release from Isolation letter. Please contact the Rockland County COVID-19 Call Center at 845-238-1956.

Symptoms Experienced
Have you experienced any symptoms that a medical provider determined were the result of COVID-19 infection, which could include: fever, cough, shortness of breath, respiratory distress, abdominal pain, fatigue, and others? *

Yes No

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

Yes No
I certify that I have not had a fever in at least 72 hours, and have not taken any fever-reducing medication (such as Tylenol) in that same period of time. *

Yes No
I certify that any respiratory issues I have suffered have improved. *

Yes No

Asymptomatic Isolation
I certify that it has been at least ten (10) days since I tested positive for COVID-19. *

Yes No
I certify that I have not experienced ANY of the following symptoms: fever, cough, shortness of breath, or other respiratory distress. *

Yes No

Request Denied
At this time, your answers indicated you are not qualified to be released from isolation. As such, you remain under isolation as set forth in the Standing Commissioner's Order. Please review the Standing Order to determine when you are qualified to end your isolation.

Release from Quarantine Certification
I certify that I have not tested positive for COVID-19: *

Yes No
I certify that it has been at least 14 days since I last had prolonged, close (within 6 feet) contact with a person who was infected with COVID-19: *

Yes No
I certify that I have not experienced ANY of the following symptoms: fever, cough, shortness of breath, or other respiratory distress: *

Yes No

Your request has been denied
At this time, your answers indicated you are not qualified to be released from quarantine. If you are experiencing symptoms of COVID-19, you should contact your doctor to determine if you should receive a test. If you are not experiencing symptoms of COVID-19, you can request another letter once 14 days have passed since your last exposure.

Personal Information
First Name *
Middle Initial
Last Name *
Suffix
Date of Birth *

Month Day Year
Date
Address *
Address 2
City *
State *
Zip Code *
Home Phone *
Enter cell phone below if home phone is not available.
Cell Phone *
Enter home phone above if cell phone is not available.
Email *

Confirmation Email
NOTE: If approved, a Release from Quarantine/Isolation Letter will be sent to the address entered above. You must have access to this email address to receive the letter.

Certification
False Statements Certification *

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 § 210.45.
Electronic Delivery Consent *

I consent to electronic delivery of a release from quarantine/isolation letter from the Rockland 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 checking this box, I release the County of Rockland from any liability that might arise from transmission of a release from quarantine/isolation letter through electronic means to the email address listed above.
Release from medical isolation understand *

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