Healthcare Official Attestation

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Executive Order 2020-32
Requesting Exemption from Executive Order 2020-10: Elective Surgeries

Email *

*This attestation must be signed by one of the following healthcare officials, as applicable:

- 𝐈𝐟 𝐚 𝐩𝐫𝐨𝐯𝐢𝐝𝐞𝐫, 𝐧𝐨𝐭 𝐥𝐢𝐜𝐞𝐧𝐬𝐞𝐝 𝐛𝐲 𝐭𝐡𝐞 𝐀𝐫𝐢𝐳𝐨𝐧𝐚 𝐃𝐞𝐩𝐚𝐫𝐭𝐦𝐞𝐧𝐭 𝐨𝐟 𝐇𝐞𝐚𝐥𝐭𝐡 𝐒𝐞𝐫𝐯𝐢𝐜𝐞𝐬 𝐚𝐬 𝐚 𝐡𝐞𝐚𝐥𝐭𝐡 𝐜𝐚𝐫𝐞 𝐢𝐧𝐬𝐭𝐢𝐭𝐮𝐭𝐢𝐨𝐧, 𝐭𝐡𝐞 𝐡𝐞𝐚𝐥𝐭𝐡 𝐩𝐫𝐨𝐟𝐞𝐬𝐬𝐢𝐨𝐧𝐚𝐥 𝐚𝐬 𝐝𝐞𝐟𝐢𝐧𝐞𝐝 𝐛𝐲 𝐀.𝐑.𝐒. § 𝟑𝟐-𝟑𝟐𝟎𝟏;
- 𝐈𝐟 𝐚 𝐥𝐢𝐜𝐞𝐧𝐬𝐞𝐝 𝐡𝐞𝐚𝐥𝐭𝐡 𝐜𝐚𝐫𝐞 𝐢𝐧𝐬𝐭𝐢𝐭𝐮𝐭𝐢𝐨𝐧 𝐢𝐬 𝐚𝐧 𝐢𝐧𝐝𝐢𝐯𝐢𝐝𝐮𝐚𝐥, 𝐭𝐡𝐞 𝐨𝐰𝐧𝐞𝐫 𝐨𝐟 𝐭𝐡𝐞 𝐡𝐞𝐚𝐥𝐭𝐡 𝐜𝐚𝐫𝐞 𝐢𝐧𝐬𝐭𝐢𝐭𝐮𝐭𝐢𝐨𝐧;
- 𝐈𝐟 𝐚 𝐥𝐢𝐜𝐞𝐧𝐬𝐞𝐝 𝐡𝐞𝐚𝐥𝐭𝐡 𝐜𝐚𝐫𝐞 𝐢𝐧𝐬𝐭𝐢𝐭𝐮𝐭𝐢𝐨𝐧 𝐢𝐬 𝐚 𝐩𝐚𝐫𝐭𝐧𝐞𝐫𝐬𝐡𝐢𝐩 𝐨𝐫 𝐜𝐨𝐫𝐩𝐨𝐫𝐚𝐭𝐢𝐨𝐧, 𝐨𝐧𝐞 𝐨𝐟 𝐭𝐡𝐞 𝐩𝐚𝐫𝐭𝐧𝐞𝐫𝐬𝐡𝐢𝐩’𝐬 𝐨𝐫 𝐜𝐨𝐫𝐩𝐨𝐫𝐚𝐭𝐢𝐨𝐧’𝐬 𝐨𝐟𝐟𝐢𝐜𝐞𝐫𝐬;
- 𝐈𝐟 𝐚 𝐥𝐢𝐜𝐞𝐧𝐬𝐞𝐝 𝐡𝐞𝐚𝐥𝐭𝐡 𝐜𝐚𝐫𝐞 𝐢𝐧𝐬𝐭𝐢𝐭𝐮𝐭𝐢𝐨𝐧 𝐢𝐬 𝐚 𝐠𝐨𝐯𝐞𝐫𝐧𝐦𝐞𝐧𝐭𝐚𝐥 𝐚𝐠𝐞𝐧𝐜𝐲, 𝐭𝐡𝐞 𝐡𝐞𝐚𝐝 𝐨𝐟 𝐭𝐡𝐞 𝐠𝐨𝐯𝐞𝐫𝐧𝐦𝐞𝐧𝐭𝐚𝐥 𝐚𝐠𝐞𝐧𝐜𝐲.

Full Name: *

I, 𝐡𝐞𝐫𝐞𝐛𝐲 𝐚𝐭𝐭𝐞𝐬𝐭 in submitting this form that the facility identified below meets and has established the minimum criteria as outlined in Executive Order 2020-32, including that the facility has and will maintain the following: *

A continuing supply of PPE that will support the facility for more than 14 days and the supply is not reliant on the state or a county health department.

Adequate staffing and bed availability with no greater than 80% of total bed capacity occupied, if the facility is a hospital.

Implemented a robust COVID-19 testing plan to test all at-risk healthcare workers and each patient prior to the scheduling of an elective, non-essential surgery during the pre-operative time period.

Implemented a process to identify, inventory, and document the availability of PPE, test collection kits, and the availability of a lab that can run the COVID-19 diagnostic test.

Implemented a universal symptom screening process for all staff, patients, and visitors prior to entry into the facility.

Implemented an enhanced cleaning process for patient and waiting areas.

Implemented policies and procedures for appropriate discharge planning of patients, including pre-discharge diagnostic COVID-19 testing for patients transferring to a nursing care institution, residential care institution setting, or Group Home for the Developmentally Disabled.

Implemented policies and procedures that prioritize elective, non-essential surgeries based upon urgency following the Centers for Medicaid and Medicare Services (CMS) Adult Elective Surgery and Procedures Recommendations.

Required

̲D̲̲i̲̲s̲̲c̲̲l̲̲o̲̲s̲̲u̲̲r̲̲e̲:

On March 19, 2020, Governor Ducey issued Executive Order 2020-10, Delaying Elective Surgeries to Conserve Personal Protective Equipment Necessary to Test and Treat Patients with COVID-19. (“E.O.2020-10”). Pursuant to this Order, beginning on Saturday, March 21, at 8:00 A.M., all non-essential or elective surgeries, including elective dental surgeries, that utilize personal protective equipment or ventilators shall not be performed at any licensed healthcare facility or by any licensed healthcare provider in the State of Arizona, until further notice. A non-essential or elective surgery means a surgery that can be delayed without undue risk to the current or future health of a patient.

On April 22, 2020, Governor Ducey issued Executive Order 2020-32, Requesting Exemption from Executive Order 2020-10, Elective Surgeries. (“E.O. 2020-32”). Pursuant to this Order, the Arizona Department of Health Services shall establish 𝐦𝐢𝐧𝐢𝐦𝐮𝐦 𝐜𝐫𝐢𝐭𝐞𝐫𝐢𝐚 that hospitals, healthcare facilities, and providers (including dental surgery providers) must demonstrate in a request for exemption from E.O. 2020-10. Furthermore, E.O. 2020-32 requires the Arizona Department of Health Services to implement a process for hospitals, healthcare facilities and providers to request an exemption from E.O. 2020-10 and 𝐝𝐞𝐦𝐨𝐧𝐬𝐭𝐫𝐚𝐭𝐞 𝐭𝐡𝐞𝐲 𝐦𝐞𝐞𝐭 𝐭𝐡𝐞 𝐦𝐢𝐧𝐢𝐦𝐮𝐦 𝐜𝐫𝐢𝐭𝐞𝐫𝐢𝐚 𝐭𝐨 𝐫𝐞𝐬𝐮𝐦𝐞 𝐞𝐥𝐞𝐜𝐭𝐢𝐯𝐞, 𝐧𝐨𝐧-𝐞𝐬𝐬𝐞𝐧𝐭𝐢𝐚𝐥 𝐬𝐮𝐫𝐠𝐞𝐫𝐢𝐞𝐬. Those receiving an exemption from E.O. 2020-10 may begin these surgeries on or after May 1, 2020.

A hospital, healthcare facility or provider who has received an exemption from E.O. 2020-10 𝐢𝐬 𝐧𝐨𝐭 𝐞𝐥𝐢𝐠𝐢𝐛𝐥𝐞 𝐭𝐨 𝐫𝐞𝐪𝐮𝐞𝐬𝐭 𝐨𝐫 𝐫𝐞𝐜𝐞𝐢𝐯𝐞 𝐏𝐏𝐄 𝐝𝐢𝐬𝐭𝐫𝐢𝐛𝐮𝐭𝐞𝐝 𝐛𝐲 𝐭𝐡𝐞 𝐬𝐭𝐚𝐭𝐞 𝐨𝐫 𝐜𝐨𝐮𝐧𝐭𝐲 𝐡𝐞𝐚𝐥𝐭𝐡 𝐝𝐞𝐩𝐚𝐫𝐭𝐦𝐞𝐧𝐭𝐬.

To review up-to-date information regarding ADHS’ emergency response to COVID-19 and information for healthcare providers, facilities and partners, including PPE contingent use guidelines, please visit: https://www.azdhs.gov/preparedness/epidemiology-disease-control/infectious-disease-epidemiology/index.php#novel-coronavirus-healthcare-providers

Notwithstanding any exemption obtained pursuant to Executive Order 2020-32, if the Arizona Department of Health Services becomes aware of actions taken by any hospital, healthcare facilities, and providers (including dental surgery providers), as a result of an exemption that jeopardizes the health, safety, and welfare of patients, the Arizona Department of Health Services will take action as necessary to protect the health, safety, and welfare of those individuals.

By receiving this exemption, the health care official agrees to retain any records related to the exemption for a period of 1 year.

Name of the Facility: *

Address: *

City: *

County: *

Type of Facility or Provider: *

Health professional as defined in A.R.S.§ 32-3201.

Licensed health care institution

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