18 November, 2021 19:04

November 18, 2021
Sample COVID-19 Vaccination Policy and Exemption Forms
Dear RHC,
We have designed a sample COVID-19 vaccine policy along with the forms for medical and religious exemption requests. The policy and forms were created in collaboration with other documents we have seen in the marketplace. This is not intended as legal counsel but is our best effort to help you get a policy in place ahead of the mandate on December 5, 2021. Please pay close attention to section 6. A-F. You will need to update this section based on your clinic’s protocols for exempted employees.

We hope that these tools are helpful to you as you strive to adhere to 42CFR 491.8(d). We are still awaiting the official interpretive guidelines from CMS on how this will be measured at survey. Once that guidance is released, we will inform you of any edits that may be needed to the attached templates.

We appreciate your efforts to continuously provide quality patient care in the midst of this ever evolving pandemic.

Julie Quinn, CPA, MBA
VP Compliance & Cost Reporting
Health Services Associates
Southeast Regional Office
ph: (231)250-0244
fax: (888)200-4788

Sample COVID-19 Vaccine Policy
Sample Medical Exemption Form
Sample Religious Exemption Form

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