COVID-19 Disability Hospital Form

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Date Created: May 21, 2020
Publication Code: HC12

Please answer the questions on this form to help physicians provide you with proper medical treatment in case you need to go to the hospital for COVID-19 related symptoms. Complete as many of the questions as possible.

This form can be completed online and printed out, or your can print it out and write in your answers. Keep it on you with other important items, like in your wallet or purse, so you have it if needed.

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