The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

6LfEKFSj9k2NF8eppjyg5sF3xvgox5Rk4AEyaVcgFoxAJRk6YDYXRcjTMFN3R6RZosT4QHaFEzYhQIM

COVID-19 Therapeutics Navigator Request Form

Please complete this form to request the support of a navigator to help a shelter guest access COVID-19 therapeutics.

Navigators may be able to support you and/or the patient with the following activities:

Identify a healthcare provider to conduct medical assessment and prescribe COVID-19 therapeutics
Schedule medical appointments including telehealth visits
Arrange transportation for medical visits and prescription pick-up or delivery

People may be eligible for COVID-19 therapeutics if they meet the following criteria:

Patient tested positive for SARS-CoV-2 (PCR or antigen).
Patient has symptoms consistent with mild to moderate COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell, or lower respiratory disease with SpO2 ≥94% on room air at sea level).
Patient is within 5-7 days of symptom onset (5 days for oral antivirals or 7 days for monoclonal antibody therapy).
Patient is at risk for developing severe illness from COVID-19. This includes, but is not limited to, having one or more of the medical conditions listed below. Note that the more underlying conditions a person has, the higher the risk for severe COVID-19 outcomes.

Following is a list of conditions that may place a person at high risk for severe illness (this does not include all potential risk factors).

50 years of age or older

Cancer

Chronic kidney disease

Chronic liver disease

Chronic lung diseases

Cystic fibrosis

Dementia or other neurological conditions

Diabetes (type 1 or type 2)

Disabilities

Heart conditions

HIV infection

Immunocompromised condition or weakened immune system

Mental health conditions

Overweight and obesity

Physical inactivity

Pregnancy

Sickle cell disease or thalassemia

Smoking, current or former

Solid organ or blood stem cell transplant

Stroke or cerebrovascular disease

Substance use disorders

Tuberculosis

Source: CDC People with Certain Medical Conditions

See the MDH resource, COVID-19 Therapeutics Checklist for Shelter and Correctional Settings for additional information.

If you have questions, please contact the COVID-19 Highly Impacted Settings Unit at Health.R-congregate@state.mn.us

Date submitted

M-D-Y

Patient consent is required in order to request navigator support from MDH.

Please do not continue until you get patient consent for COVID-19 navigation support.

If you would like educational materials to share with the patient, see the following resources

MDH handout on COVID-19 Medications: Oral Antivirals
MDH website with information about COVID-19 Medications for the general public

Name of person completing this form

* must provide value

Facility name

* must provide value

Facility address

* must provide value

Facility county

Facility phone number

* must provide value

Alternate phone number

Email address:

* must provide value

Does your facility have a healthcare provider who can see patients on site?

Yes

reset

Does your facility have equipment to support telehealth visits for patients?

To access telehealth facilities will need a secure phone, laptop, or computer, and high-speed internet access.

* must provide value

Yes

I'm not sure

reset

Does your facility have private space for patients to participate in a telehealth visit?

Yes

reset

Does your facility have staff who can help patients log in to telehealth visits?

Yes

reset

Does your facility offer transportation assistance for patients accessing healthcare off site including clinic visits, pharmacy, etc.?

Yes

reset

This information is used to help the navigator identify the most appropriate referral option and to schedule appointments if necessary.

Patient first name

* must provide value

Patient last name

* must provide value

Patient date of birth

* must provide value

M-D-Y

Patient phone number

Patient email

Date COVID-19 symptoms started

* must provide value

M-D-Y

Date of positive COVID-19 test

* must provide value

M-D-Y

Does the patient have health insurance?

* must provide value

Yes

I don't know

reset

Name of insurance carrier

Group number

Member ID

Does patient have a regular health care provider?

Yes

I don't know

reset

Name of regular health care clinic

Clinic address

Clinic county

If oral antivirals are prescribed, do you or the patient have a pharmacy you prefer to use?

Yes

reset

Pharmacy name

Pharmacy address

Patient preferred language

Does the patient need any additional accommodations?

Yes

reset

Please describe additional accommodations needed

Expand

Is there anything else the navigator should know in order to best support this patient?

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.