Get Ny Covid-19 Screening Form 2020-2026

The NY Covid-19 Screening Form is an essential document for individuals seeking admission to New York State Office of Mental Health's inpatient services. This guide will provide clear instructions on completing the form online to ensure a smooth and efficient process.

Follow the steps to complete the NY Covid-19 Screening Form online

1. Press the ‘Get Form’ button to obtain the screening form and open it in your designated editor.
2. Begin filling out the form by entering the patient's name and date of birth in the appropriate fields to ensure accurate identification.
3. Answer the first question regarding international travel to a CDC-designated Level 2 or Level 3 country within the last 14 days. If 'Yes,' provide the travel details, testing status, and any pertinent information in the designated space.
4. Respond to the question about visiting a domestic area with high COVID-19 prevalence in the last 14 days. If applicable, include the relevant location, testing information, and details.
5. Indicate whether the patient has had direct contact with a confirmed COVID-19 positive individual. If 'Yes,' document any testing that has occurred.
6. Address the symptoms section by checking 'Yes' or 'No' for fever, sore throat, cough, and shortness of breath. If 'Yes,' provide details on symptom history and management.
7. If symptoms are reported, check if the patient has any comorbid pulmonary conditions and include the necessary details.
8. Fill in the name of the referring facility and referring physician/nurse practitioner, including their contact number.
9. The referring physician/nurse practitioner should provide their signature, the date of completion, and the time of completion using military time.
10. Review all entries for accuracy. Save your changes, and once complete, download, print, or share the form as required.

Complete the NY Covid-19 Screening Form online today to ensure timely processing of your application.