Attached is a form developed at Stony Brook University by M Ballan and C. Perri.

Their purpose is to ensure friends, family members and clients receive quality medical treatment from hospital physicians, should a hospital encounter become necessary.

Most hospitals are not allowing staff or loved ones to accompany patients for treatment. After learning of several cases of inferior and/or discriminatory treatment for individuals with disabilities in New York hospitals, they created the attached form which has been reviewed by ER physicians, families of individuals and adults with intellectual and developmental disabilities. The goal is to complete this form prior to seeking medical attention for COVID-19 symptoms. Having this form, and the accompanying documents noted on page 2 of the form, will help to alert ER physicians to necessary and proper communication with the patient with disabilities and his/her needs and wishes.  It has been reviewed by ER physicians, families of individuals with disabilities and adults with disabilities.

Please disseminate the form to your networks and individuals with disabilities.   They ask that if you share or cite this form, please use the following: Ballan, M. & Perri, C. (2020). Covid-19 Disability Form. Stony Brook, NY

They are encouraging people to complete it, with the hope that it will not be needed!

There are two copies.  It’s been converted to be a fillable form and on p. 2 added a place to add a parent’s or health advocate’s contact information.  The other is a form to print and complete by hand.

Please share it with anyone it can help.
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