Florida Health Medical Exemption from COVID-19 Vaccination
This file is for employees seeking a medical exemption from COVID-19 vaccination in Florida. It includes sections for both the employee and their medical provider to fill out. The completed form must be submitted to the employer to opt-out of a vaccination mandate.
Edit, Download, and Sign the Florida Health Medical Exemption from COVID-19 Vaccination
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out this form, first complete the employee section with your personal details. Next, have your medical provider fill out their section with the required medical opinion and signature. Finally, submit the form to your employer to request the exemption.
How to fill out the Florida Health Medical Exemption from COVID-19 Vaccination?
1
Complete the employee section with your personal details.
2
Have your medical provider fill out their section with the required medical opinion and signature.
3
Ensure all fields are accurately filled out.
4
Review the completed form for any errors or missing information.
5
Submit the form to your employer to request the exemption.
Who needs the Florida Health Medical Exemption from COVID-19 Vaccination?
1
Pregnant employees who require a medical exemption from COVID-19 vaccination.
2
Employees anticipating pregnancy and seeking exemption.
3
Employees with medical conditions that contraindicate COVID-19 vaccination.
4
Employees whose physicians believe vaccination is not in their best medical interest.
5
Employers and HR departments managing vaccination mandates.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the Florida Health Medical Exemption from COVID-19 Vaccination along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your Florida Health Medical Exemption from COVID-19 Vaccination online.
With PrintFriendly, you can easily edit this PDF by entering your information directly into the fillable fields. Use the editing tools to make any necessary changes or corrections. Save and download the edited PDF for your records.
Add your legally-binding signature.
PrintFriendly allows you to sign PDFs electronically. Add your signature by using the signature tool in the PDF editor. Save and download the signed PDF for submission.
Share your form instantly.
You can share PDFs on PrintFriendly by using the sharing options available in the PDF editor. Share your completed form via email, link, or other available methods. Ensure the recipient receives the form securely and promptly.
How do I edit the Florida Health Medical Exemption from COVID-19 Vaccination online?
With PrintFriendly, you can easily edit this PDF by entering your information directly into the fillable fields. Use the editing tools to make any necessary changes or corrections. Save and download the edited PDF for your records.
1
Open the PDF in PrintFriendly's PDF editor.
2
Enter your information directly into the fillable fields.
3
Use the editing tools to make any necessary changes or corrections.
4
Review the edited form for accuracy.
5
Save and download the edited PDF.
What are the instructions for submitting this form?
To submit this form, fill out the employee section and have your medical provider complete their portion. Review the form for accuracy and ensure all required fields are filled. Submit the completed form to your employer through the specified method, which may include email, fax, or physical delivery. Follow your employer's guidelines for submission to ensure your exemption request is processed. If submitting via email or fax, verify the correct contact details. If submitting a physical copy, ensure it is delivered to the correct office or department.
What are the important dates for this form in 2024 and 2025?
There are no specific dates mentioned for 2024 and 2025 in this form. Please refer to your employer for relevant deadlines and submission dates.
What is the purpose of this form?
The purpose of the COVID-19 Medical Exemption Form is to allow employees in Florida to request an exemption from COVID-19 vaccination based on medical grounds. This form is intended for use by employees who are pregnant, anticipating pregnancy, or have medical conditions that contraindicate vaccination. The completed form, signed by a licensed medical provider, must be submitted to the employer to opt-out of a COVID-19 vaccination mandate.
Tell me about this form and its components and fields line-by-line.
- 1. Employee Name: The full name of the employee requesting the exemption.
- 2. Date of Birth: The employee's birth date.
- 3. Phone Number: The employee's contact phone number.
- 4. Employer Name: The name of the employee's employer.
- 5. Date of Request: The date when the exemption request is being made.
- 6. Pregnancy Basis: An option for the employee to indicate if the exemption is due to pregnancy or anticipated pregnancy.
- 7. Medical Provider Name: The full name of the medical provider completing the form.
- 8. Medical Provider Signature: The signature of the medical provider.
- 9. Medical Provider License Number: The license number of the medical provider.
- 10. Date: The date when the medical provider signed the form.
What happens if I fail to submit this form?
If you fail to submit this form, you may not be granted an exemption from your employer's COVID-19 vaccination mandate. Ensure timely submission to avoid any negative consequences.
- Exemption Denied: Your request for a medical exemption from COVID-19 vaccination may be denied.
- Employment Impact: Failure to comply with the vaccination mandate may impact your employment status.
How do I know when to use this form?
- 1. Pregnancy Exemption: Use this form if you are pregnant or anticipating pregnancy and require an exemption.
- 2. Medical Condition: Use this form if you have a medical condition that contraindicates COVID-19 vaccination.
- 3. Medical Opinion: Use this form if your physician advises against COVID-19 vaccination for your health.
- 4. Employer Mandate: Use this form to comply with your employer's requirement for submitting a medical exemption.
- 5. Official Exemption: Use this form to officially document your request for exemption to your employer.
Frequently Asked Question
How do I fill out the COVID-19 Medical Exemption Form?
Complete the employee section with your details and have your medical provider fill out their section. Save and download the completed form for submission.
Who can sign the medical provider section?
A physician, physician assistant, or advanced practice registered nurse with a valid Florida license can sign the medical provider section.
Can I edit the form on PrintFriendly?
Yes, you can easily edit the form using PrintFriendly's PDF editor by entering information directly into the fillable fields.
How do I sign the form on PrintFriendly?
Use the signature tool in PrintFriendly's PDF editor to add your electronic signature. Save and download the signed PDF.
How do I share the completed form?
Share the completed form via email, link, or other available methods using PrintFriendly's sharing options.
Is the form valid if signed electronically?
Yes, electronic signatures are valid as long as they meet the requirements outlined by relevant regulations.
Do I need to submit the form to my employer?
Yes, the completed form must be submitted to your employer to request the exemption from COVID-19 vaccination.
Can I save the form after editing?
Yes, save the form after editing or signing by using the save and download feature in PrintFriendly.
What should I do if there are errors in the form?
Use PrintFriendly's editing tools to correct any errors before saving and downloading the form.
Is there a deadline for submitting the form?
Check with your employer for specific deadlines. It is important to submit the form as soon as possible to ensure your exemption request is processed.
Related Documents - COVID-19 Medical Exemption Form
Maryland DPSCS COVID-19 Exemption Form
This document is the COVID-19 Medical and Religious Exemption Form used by the Maryland Department of Public Safety and Correctional Services (DPSCS) for employees requesting an exemption from COVID-19 related requirements.
