I understand that on November 5, 2021, the Centers for Medicare and Medicaid Services (CMS) enacted an emergency regulation which mandates the COVID-19 vaccination of eligible staff at health care facilities that participate in the Medicare and Medicaid programs.
By signing this declination form, I acknowledge that I have read and understand its contents and am declining the COVID-19 vaccine due to a medical exemption or a sincerely held religious belief. If requested, I can provide documentation supporting an exemption.
Declination of Vaccination:
• I have received information regarding the risks and benefits of receiving a COVID-19 vaccine.
• I am declining vaccination due to medical contraindications or a sincerely held religious belief.
• I understand that I may be at risk of contracting COVID-19 and/or spreading it to others.