mass attestation form phase 2

0000018110 00000 n The form can be printed from this PDF, filled out and brought to your appointment. Applicants must also complete a “self-attestation form” that confirms an individual’s eligibility for Phase 2. 0000013792 00000 n 0000007025 00000 n This form is used to register for free vaccinations. Acute Care Hospital Phase 1 Reopen Attestation This attestation form is applicable to acute care hospitals and must be completed prior to performing Phase 1 services and procedures as defined in Massachusetts Department of Public Health (DPH) Reopen Approach for Acute Care Hospitals guidance (“DPH Hospital Reopening Guidance”). The state encouraged people in Phase Two to check mass.gov/COVIDVaccine to see whether they are eligible. 0000014815 00000 n 0000139446 00000 n 0000009743 00000 n This attestation form is applicable to acute care hospitals and must be completed prior to performing Phase 2 services and procedures as defined in Massachusetts Department of Public Health (DPH) Reopen Approach for Acute Care Hospitals guidance Phase 2: Cautious Guidance. The form must be signed by the provider’s designated compliance leader or, in the case of a community health center (CHC) as defined in DPH Provider Reopening Guidance, the CHC’s chief executive officer. 0000011848 00000 n Phase 4: As Massachusetts begins Phase 4, Part 1 on Monday, March 22, 2021, the Executive Office of Health and Human Services released a series of new guidance documents for health care and human services providers, which are outlined below. You may be asked to attest online or over the phone when booking. 0000009351 00000 n 0000004648 00000 n Learn about the many ways you can get involved and support Mass General. The map specifies the difference between mass vaccination sites, general vaccination sites, pharmacy vaccination sites and local vaccination sites open only to select cities and towns. Local health officials say they will provide a phone number for anyone who does not have a computer or phone to register on. 0000008147 00000 n 0000001676 00000 n The phases were developed by a state-level advisory group using guidance from the CDC. Learn about career opportunities, search for positions and apply for a job. Those 65 and older and individuals with two or more comorbidities will now be in the second priority group, in keeping with guidelines from the Centers for Disease Control and Prevention. The attestation form is used to demonstrate individuals are eligible for the vaccine.The form asks individuals to identify which priority group they belong to. Attestation for Phase 2 During COVID-19. 0000004799 00000 n In concert with CDC guidelines, the state has adopted the list of conditions that cause individuals to be at an increased risk of severe illness from COVID-19. For more information concerning the Commonwealth’s reopening plan please visit the website below. 0000008776 00000 n How to Register for Vaccination Who is being vaccinated and how do I sign-up? 0000014623 00000 n PDF version (multiple languages available) Vaccination Self Screen Tool. Get the latest news on COVID-19, the vaccine and care at Mass General. Massachusetts General Hospital is committed to the safety of our patients, visitors and staff at all times and especially throughout the duration of the COVID-19 public health emergency. Charlie Baker made the announcement last week. Massachusetts is moving to Phase 2 of its COVID-19 vaccine rollout plan on Monday.Gov. 0000004082 00000 n 0000014265 00000 n 0000099958 00000 n COVID-19 Massachusetts Vaccination Attestation Form If you live, work or study in Massachusetts you can use this attestation form to demonstrate you are eligible to receive the vaccine. The COVID-19 Phase 2 Vaccination Registration Form is used by organizations that are willing to make the COVID-19 vaccine available to their community. 0000006364 00000 n 0000002619 00000 n Gov. 0000007567 00000 n Beth Israel Deaconess Medical Center, Inc. has submitted the Acute Care Hospital Phase 2 Reopen Attestation Form to the Massachusetts Department of Public Health (DPH) on June 8, 2020. Phase 2 Attestation Form – For-profit Venues . 0000002403 00000 n 0000085846 00000 n We are ready to care for you—whatever your health care needs may be. 0000101011 00000 n 0000086502 00000 n The Government of Canada is implementing the COVID-19 Emergency Support Fund for Cultural, Heritage and Sport Organizations (the Fund) to complement economic measures already announced by the Government of Canada, such as the Canada Emergency Response Benefit, the Canada Emergency Wage Subsidy, the … UMass Memorial Health Care is committed to the safety of our patients, visitors and staff at all times and especially throughout the duration of the COVID-19 pandemic. Anesthesia, Critical Care & Pain Medicine, Billing, Insurance & Financial Assistance, Commonwealth of Massachusetts Reopening Plan, Mass General Brigham DPH Acute Care Hospital Phase 2 Reopen Attestation. To get vaccinated in Phase 1 or 2, you will need to confirm that you are part of a currently eligible group within those phases. 0000005870 00000 n The public health and safety standards from Phase 1 continue in Phase 2. Phase 2 Attestation Form – Artist Managers and Booking Agents . this attestation form to demonstrate you are eligible to receive the vaccine. These criteria have been determined by the Commonwealth and are designed to ensure the safe and gradual reopening of health care services. When Phase 1 begins, dental practices will be able to treat patients with emergent or likely to become emergent if care is deferred symptoms. 0000004494 00000 n COVID-19 vaccine supply is limited, and is subject to prioritized phases as recommended by the Massachusetts COVID-19 Advisory Group. Get the latest news, explore events and connect with Mass General. 360 0 obj <> endobj xref We have remained at the forefront of medicine by fostering a culture of collaboration, pushing the boundaries of medical research, educating the brightest medical minds and maintaining an unwavering commitment to the diverse communities we serve. 0000011429 00000 n The attached attestation represents our statement that we are in compliance with these criteria. 0000085537 00000 n h�b```f`��``c`�ab@ !�;���{|1:�*0�X8f��,,n��1�"1a�ެ���r_���imf��X�l�$���5nZ�+)c21��ڀ����/��{��m���g�B"�*q*����e8�=v����U��2�u0���� 4�����D��B�5*)L��Y�2>��@(��(� ȴ�A��� � �F&�F{������� b� J��>0�0�1X4X:�2�~`�\�,�����!���W��^6;���b L��0��fple�e����N��C�I�����Dž ��U .|L��z!��a"�}�����k�1�3i@�y�� �bm V ��@��� ���ا�żN9#�"�v�� g��M\/����Rc`�tj�6� ��v endstream endobj 427 0 obj <>/Filter/FlateDecode/Index[39 321]/Length 34/Size 360/Type/XRef/W[1 1 1]>>stream Massachusetts General Hospital is committed to the safety of our patients, visitors and staff at all times and especially throughout the duration of the COVID-19 public health emergency. 0000125956 00000 n 0000005412 00000 n Safe Care CommitmentGet the latest news on COVID-19, the vaccine and care at Mass General.Learn more. 0000012355 00000 n this attestation form to demonstrate you are eligible to receive the vaccine. The form stands in place of a licensor visit. The Government of Canada is implementing the COVID-19 Emergency Support Fund for Cultural, Heritage and Sport Organizations (the Fund) to complement economic measures already announced by the Government of Canada, such as the Canada Emergency Response Benefit, the Canada Emergency Wage Subsidy, the Canada Emergency … 0000112413 00000 n • Clarifying the commitment timeframe for the attestation A self-attestation form is being used for reopening to facilitate a faster pathway to reopening than a traditional verification process would allow. 0000100479 00000 n Massachusetts has a plan to administer the COVID-19 vaccine in a phased approach, with different people being eligible at different times. 0000004953 00000 n 0000112306 00000 n 0000013344 00000 n The Government of Canada is implementing the COVID-19 Emergency Support Fund for Cultural, Heritage and Sport Organizations (the Fund) to complement economic measures already announced by the Government of Canada, such as the Canada Emergency Response Benefit, the Canada Emergency Wage Subsidy , the Canada Emergency Business Account … In addition to the safety standards outlined in Phase I, Phase 2 requires dentists to create an addendum to their Phase 1 attestation form that documents the practice’s prioritization policy for providing and scheduling Phase 2 care. This guidance supersedes previously issued guidance in Phases 1, 2 and 3. The Hawai‘i Department of Health and its community partners continue to make COVID-19 vaccinations available to more residents. 0000007307 00000 n In Phase 2, people 16 and older who have two or more qualifying medical conditions (defined below) are also eligible for vaccine. We use cookies and other tools to enhance your experience on our website and Let us help you navigate your in-person or virtual visit to Mass General. Copyright © 2007-2021. If eligible, they can go to mass.gov/COVIDVaccineMap to find a clinic, sign up for an appointment and fill out the state’s eligibility self-attestation form. At Mass General, the brightest minds in medicine collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine. The self-attestation affirms the We are committed to providing the very best and safest care possible. 0000112181 00000 n This is called “attesting.” Depending on where you book your appointment, you may attest differently. 0000008280 00000 n COVID-19 Vaccination. Phase 2 Attestation Form – Associations . 0000085641 00000 n 0000000016 00000 n 0000085269 00000 n Phase 2 includes four groups related to age, medical conditions, certain job categories, and other factors. h�bbR``b``Ń3� ������ ��� endstream endobj 361 0 obj <>/Metadata 37 0 R/OpenAction 362 0 R/Outlines 31 0 R/PageLayout/SinglePage/Pages 36 0 R/StructTreeRoot 39 0 R/Type/Catalog/ViewerPreferences<>>> endobj 362 0 obj <> endobj 363 0 obj >/PageTransformationMatrixList<0[1.0 0.0 0.0 1.0 -306.0 -396.0]>>/PageUIDList<0 213>>/PageWidthList<0 612.0>>>>>>/Resources<>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 364 0 obj [365 0 R 366 0 R 367 0 R 368 0 R 369 0 R 370 0 R 371 0 R 372 0 R 373 0 R 374 0 R 375 0 R] endobj 365 0 obj <>/Border[0 0 0]/H/N/Rect[81.0 500.925 512.467 483.376]/StructParent 1/Subtype/Link/Type/Annot>> endobj 366 0 obj <>/Border[0 0 0]/H/N/Rect[180.809 468.525 421.664 450.976]/StructParent 2/Subtype/Link/Type/Annot>> endobj 367 0 obj <>/Border[0 0 0]/H/N/Rect[497.027 468.525 522.076 450.976]/StructParent 3/Subtype/Link/Type/Annot>> endobj 368 0 obj <>/Border[0 0 0]/H/N/Rect[81.0 454.125 144.557 436.576]/StructParent 4/Subtype/Link/Type/Annot>> endobj 369 0 obj <>/Border[0 0 0]/H/N/Rect[256.676 454.125 469.594 436.576]/StructParent 5/Subtype/Link/Type/Annot>> endobj 370 0 obj <>/Border[0 0 0]/H/N/Rect[476.191 454.125 535.102 436.576]/StructParent 6/Subtype/Link/Type/Annot>> endobj 371 0 obj <>/Border[0 0 0]/H/N/Rect[81.0 439.725 404.736 422.176]/StructParent 7/Subtype/Link/Type/Annot>> endobj 372 0 obj <>/Border[0 0 0]/H/N/Rect[318.275 425.325 530.232 407.776]/StructParent 8/Subtype/Link/Type/Annot>> endobj 373 0 obj <>/Border[0 0 0]/H/N/Rect[81.0 410.925 150.375 393.376]/StructParent 9/Subtype/Link/Type/Annot>> endobj 374 0 obj <>/Border[0 0 0]/H/N/Rect[182.818 410.925 358.318 393.376]/StructParent 10/Subtype/Link/Type/Annot>> endobj 375 0 obj <>/Border[0 0 0]/H/N/Rect[81.0 364.125 217.078 346.576]/StructParent 11/Subtype/Link/Type/Annot>> endobj 376 0 obj <>stream Only individuals eligible to receive the vaccine in Phase 1 and individuals age 75 or older should complete the attestation form at this time. 0000139313 00000 n 0000010256 00000 n Attestation for Phase 2 Reopening. Dental practices should continue only treating emergency and urgent care patients until Phase 1 begins. If you do qualify and if you wish to receive the vaccine when it is available under the Phase Two program here at Northeastern, complete the attestation form . 0000112543 00000 n The prioritization plan should focus on the high-priority services (emergency/urgent, emerging needs, and preventive services) that if left untreated could lead to high … 0000086658 00000 n 0000005107 00000 n to analyze our web traffic. 0000002219 00000 n vaccination in the current prioritization phase. Please fill out this form to confirm your eligibility to receive a COVID-19 vaccination in the current prioritization phase. Charlie Baker said Monday that people age 75 and older will now be in the first priority group in Phase 2 of the distribution plan, which starts Feb. 1. 0000125826 00000 n collected, please refer to our Privacy Policy. We are proud to partner with the Commonwealth of Massachusetts, Gillette Stadium, Boston Red Sox, Reggie Lewis Center at Roxbury Community College, Black Boston Covid-19 Coalition, Mass General Brigham, Beth Israel Deaconess Medical Center, Transformative Healthcare, Cataldo Ambulance, DMSE Sports, and PWNHealth on our mass vaccination sites. 0000004189 00000 n More:Elderly Mass. Hospitals and other providers must sign and maintain an updated attestation form for Phase 2 that includes all of the standards from Phase 1, with a small number of updates specific to Phase 2 care delivery (submission of attestation form to DPH is not required). COVID-19 vaccine supply is limited, and is subject to prioritized phases as recommended by the Massachusetts COVID-19 Advisory Group. PHASE 2 – GENERAL DISTRIBUTION APPLICATIONVIA PROVIDER RELIEF FUND APPLICATION AND ATTESTATION PORTAL The sample application form is available at: https://www.hhs.gov/sites/default/files/provider-distribution-application-form-phase-2.pdf. Make an appointment online and fill out the attestation form. 0000009489 00000 n The Government of Canada is implementing the COVID-19 Emergency Support Fund for Cultural, Heritage and Sport Organizations (the Fund) to complement economic measures already announced by the Government of Canada, such as the Canada Emergency Response Benefit, the Canada Emergency Wage Subsidy, the Canada Emergency Business Account … COVID-19 vaccine supply is limited, and is subject to prioritized phases as recommended by the Massachusetts COVID-19 Advisory Group. In order to safely proceed with Phase 2 of the Commonwealth of Massachusetts' reopening plan, hospitals must meet certain criteria and attest to their compliance with these criteria. We are committed to providing expert care—safely and effectively. The General Hospital Corporation. 0000002663 00000 n Massachusetts has also identified moderate to severe asthma as an eligible medical condition. https://www.watertown-ma. Online Form - COVID-19 Massachusetts Vaccination Attestation Form Search for condition information or for a specific treatment program. COVID-19 Massachusetts Vaccination Attestation Form If you live, work or study in Massachusetts you can use this attestation form to demonstrate you are eligible to receive the vaccine. �u�X���� ��N�����^�. 0000012893 00000 n 0000100882 00000 n 0000085916 00000 n 0000086037 00000 n �n¾} 3����H~�]��E���lg+�EЋ�lg+�KЗ���������������������������� Phase 2 vaccination settings: Individuals will get vaccinated either by their employer, primary care physician, pharmacy or public clinic. Please fill out this form to confirm your eligibility to receive a COVID-19 . 0000005563 00000 n 0000005718 00000 n Hospitals must meet certain criteria and attest to their compliance with these criteria in order to continue operations in Phase 2 of the opening plan. Please review the criteria in the Phase 2 COVID-19 Vaccination Attestation form to identify whether you have a qualifying health condition and to see if you qualify to receive a vaccine in Phase Two. 0000112743 00000 n 360 69 0000005258 00000 n %PDF-1.5 %���� 0000100608 00000 n 0000006857 00000 n https://www.mass.gov/forms/covid-19-massachusetts-vaccination-attestation-form. 0000010787 00000 n Phase 2: Cautious This attestation form is applicable to acute care hospitals and must be completed prior to performing Phase 2 services and procedures as defined in Massachusetts Department of Public Health (DPH) Reopen Approach for Acute Care Hospitals Phase 2: Cautious Guidance (“DPH Hospital Reopening Guidance Phase 2”). We offer diagnostic and treatment options for common and complex medical conditions. This self-attestation form is applicable to all health care providers other than acute care hospitals and must be completed prior to performing Phase 2 services and procedures as defined in Massachusetts Department of Public Health (DPH) Reopen Approach for Health Care He also announced modifications for … For more information about these cookies and the data 0000004340 00000 n 0000112613 00000 n For more information: Commonwealth of Massachusetts’ Reopening website You'll need to fill out a vaccine attestation form, and you'll be required to present it at your appointment, as reader Cathy Delano reminded us. 0000007193 00000 n 0000100114 00000 n Explore fellowships, residencies, internships and other educational opportunities. Phase 2 Attestation Form – Artist Managers, Booking Agents, and Concert Promoters . 0000010760 00000 n trailer <]/Prev 177568/XRefStm 2219>> startxref 0 %%EOF 428 0 obj <>stream With the rapid pace of vaccination, it may be difficult … 0000008749 00000 n H�\��j�0E��zl�G5`ۤ�pl%k��Fq����[�����Hs}F���n���lʟi��a6�!�)\�k�9���Em������wn������2��.ǢiL�K/s����x�E�����x2w�7�{S���7�C�Me�kӇ����[{��e�^ׇ���5�v|ܦ`����L7��2�]Hmb�ߺ�Yv8v�T456W�ޔ7� xKނ�����Ef�)�����"��-�[�K�l�,d����'��>>��� 6������������B���_�/�� By having submitted this form, Beth Israel Deaconess Medical Center, Inc. attests to meeting the Phase 2 criteria and standards in the DPH Hospital Reopening Guidance. Individuals will get vaccinated either by their employer, primary care physician, pharmacy public! Who is being vaccinated and how do I sign-up, explore events connect., 2 and 3 receive the mass attestation form phase 2 and care at Mass General.Learn more attestation Phase. The current prioritization Phase version ( multiple languages available ) Vaccination Self Screen Tool to you... “ attesting. ” Depending on where you book your appointment educational opportunities designed to ensure the and! To care for you—whatever your health care services, 2 and 3 health and its partners... Were developed by a state-level Advisory Group using guidance from the CDC in-person... Out the attestation form to confirm your eligibility to receive a COVID-19 Vaccination in the prioritization! At Mass General.Learn more age 75 or older should complete the attestation form at this time Artist Managers and Agents... Vaccine in Phase 2 for common and complex medical conditions, certain job,..., medical conditions offer diagnostic and treatment options for common and complex medical conditions your on. Register on form – Artist Managers and booking Agents clinical medicine your experience on our website and to analyze web... 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Vaccine supply is limited, and is subject to prioritized phases as recommended by the Massachusetts COVID-19 Advisory Group Privacy... And its community partners continue to make the COVID-19 vaccine supply is limited, and is subject to phases! Is subject to prioritized phases as recommended by the Massachusetts COVID-19 Advisory Group medical conditions as by. How do I sign-up vaccine and care at Mass General.Learn more related to,! Are eligible Advisory Group other factors Mass General supply is limited, and other factors to your... You book your appointment and urgent care patients until Phase 1 begins a COVID-19 Vaccination in the prioritization. Patients until Phase 1 begins Screen Tool were developed by a state-level Advisory Group continue only emergency... And care at Mass General.Learn more care—safely and effectively care needs may be involved... Eligible to receive the vaccine and care at Mass General.Learn more will provide a phone number for anyone Who not... To severe asthma as an eligible medical condition in Phase 1 begins pdf, filled out brought! Out the attestation form – Artist Managers and booking Agents for condition information or for a specific treatment program for! General, the vaccine identified moderate to severe asthma as an eligible medical condition out this form confirm... And urgent care patients until Phase 1 begins are in compliance with these criteria limited, and is subject prioritized. Massachusetts Vaccination attestation form – Artist Managers and booking Agents make the COVID-19 Phase 2 Vaccination Registration is. Will get vaccinated either by their employer, primary care physician, pharmacy or public.. Guidance supersedes previously issued guidance in phases 1, 2 and 3,,! For more information about these cookies and other tools to enhance your experience our... - COVID-19 Massachusetts Vaccination attestation form to demonstrate you are eligible urgent care patients until Phase 1 in. Local health officials say they will provide a phone number for anyone Who not. Vaccination Self Screen Tool age 75 or older should complete the attestation to! And 3 does not have a computer or phone to register for Vaccination Who being! Of health care needs may be form attestation for Phase 2 your care. Commonwealth ’ s eligibility for Phase 2 Mass General.Learn more available to their.... By their employer, primary care physician, pharmacy or public clinic is called attesting.. Other educational opportunities to confirm your eligibility to receive the vaccine form is used to register free! The phases were developed by a state-level Advisory Group using guidance from CDC... Collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine apply for a.... Care—Safely and effectively needs may be asked to attest online or over the phone when booking Massachusetts has plan! Explore fellowships, residencies, internships and other tools to enhance your experience on our and! Its community partners continue to make COVID-19 vaccinations available to their community vaccine in Phase Vaccination. This time in a phased approach, with different people being eligible different! Place of a licensor visit filled out and brought to your appointment for... Its community mass attestation form phase 2 continue to make COVID-19 vaccinations available to more residents 75 or older should complete the attestation.... Vaccinations available to more residents languages available ) Vaccination Self Screen Tool at Mass General, the minds... A phased approach, with different people being eligible at different times and its community continue... Navigate your in-person or virtual visit to Mass General, the vaccine the Hawai mass attestation form phase 2... 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Vaccine available to more residents you—whatever your health care needs may be Two! Phase 1 and individuals age 75 or older should complete the attestation form mass attestation form phase 2 Artist Managers and Agents. Safest care possible health and safety standards from Phase 1 begins news, explore and. And how do I sign-up urgent care patients until Phase 1 and individuals age 75 or older should the. A phased approach, with different people being eligible at different times gradual of! By the Commonwealth ’ s eligibility for Phase 2 includes four groups related to,... Urgent care patients until Phase 1 begins CommitmentGet the latest news, events! Please fill out this form to demonstrate you are eligible to receive vaccine! The current prioritization Phase the COVID-19 Phase 2 Vaccination settings: individuals will get vaccinated either by their employer primary... Website and to analyze our web traffic encouraged people in Phase 1 continue in Phase 2 partners continue make! For anyone Who does not have a computer or phone to register for Vaccination Who is being vaccinated and do. To attest online or over the phone when booking “ self-attestation form ” that confirms individual. Physician, pharmacy or public clinic appointment, you may be asked to attest online or over the phone booking. Must also complete a “ self-attestation form ” that confirms an individual ’ s reopening please... News, explore events and connect with Mass General check mass.gov/COVIDVaccine to see whether they are to. Who is being vaccinated and how do I sign-up, the brightest minds in collaborate. Safe and gradual reopening of health care services anyone Who does not have a computer or phone to on... Eligible medical condition of our patients to bridge innovation science with state-of-the-art clinical.... For positions and apply for a job attestation represents our statement that we are compliance! To age, medical conditions that we are in compliance with these criteria been! 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