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Work School Release Form

This form excuses a visitor from work or school to visit a patient in the hospital from a specified date range. It records the visitor's relationship to the patient, the reason for the visit such as an emergency, surgery, or end of life care. A medical center employee must sign and validate the excuse, providing their name, title, and contact number. The form omits the patient's name due to HIPAA privacy laws.

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1K views1 page

Work School Release Form

This form excuses a visitor from work or school to visit a patient in the hospital from a specified date range. It records the visitor's relationship to the patient, the reason for the visit such as an emergency, surgery, or end of life care. A medical center employee must sign and validate the excuse, providing their name, title, and contact number. The form omits the patient's name due to HIPAA privacy laws.

Uploaded by

api-509066604
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Work & School Release Form

Work & School Release Form

Today’s Date:___________________

Visitors Name:

____________________________________________________________

Please excuse _______________________________ from work/ school from ____/____/____ to


____/____/____.

Visitor’s Relationship to Patient:


Husband: ____
Wife: ___
Parents: ___
Grandparents:___
Children: ___
Sister/Brother: ___
Other: ____

Reason for Visitation of Patient:


Emergency:_____
Surgery:_____
End of Life Visit:____
Patient Expired:_____
Request from Clinical Staff to be Present:_____
Other:_______________

Coliseum Medical Centers Employee Signature/Date:

Excuse was validated by____________________________________________________________________


Physician:________
Clinical Staff:_______
Social Worker:_______
Patient Advocate:_______

Unit/Floor Contact Number:___________________

*Due to HIPAA laws patient’s name was omitted from this form*

Comments:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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