This is the Dep’t of Health form necessary for ‘extremely vulnerable’ to receive COVID-19 vaccine
Image via AP.

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Medical professionals don't need to identify a condition, but must attest that there is one.

As vaccines open up to “extremely vulnerable” Floridians of all ages, the Department of Health has released a form for doctors to determine eligibility.

Gov. Ron DeSantis on Monday issued an executive order that said beginning on Wednesday hospital providers, licensed physicians, and advanced practice registered nurses may vaccinate individuals “they deem to be extremely vulnerable to COVID-19.”

Who that specifically includes was left largely to the discretion of medical professionals.

“Such physician determinations shall include a statement that the patient meets the defined eligibility criteria established by a form prescribed by the Florida Department of Health.”

Late Tuesday night, health officials released the form on social media. The form itself requires verification of medical professionals’ license to practice, but does not require the disclosure of a specific medical condition. It simply required the professional to attest to a “physician-patient relationship” with the individual receiving the vaccine, and to affirm a medical determination of eligibility.

“Pursuant to EO 21-47, the Department has published a form for physicians to certify that they have determined an individual to be extremely vulnerable to COVID-19 and eligible to receive the vaccine,” reads a post on the official Twitter for the Department of Health. “This form will be used across Florida beginning (Wednesday).”

Besides those deemed “extremely vulnerable,” the vaccine is available in Florida to frontline health care workers, all individuals age 65 and older, and teachers, police and firefighters age 50 and older.

As of midday Tuesday, a total of 3,084,403 individuals in the state have received at least one dose of the Pfizer or Moderna vaccines. That includes 1,723,722 fully vaccinated individuals and 1,360,681 who received a first dose but await a second shot.

The total includes 2,340,862 individuals age 65 and older. The daily report on vaccinations does not break down vaccinations based on how individuals qualified to receive shots.

Jacob Ogles

Jacob Ogles has covered politics in Florida since 2000 for regional outlets including SRQ Magazine in Sarasota, The News-Press in Fort Myers and The Daily Commercial in Leesburg. His work has appeared nationally in The Advocate, Wired and other publications. Events like SRQ’s Where The Votes Are workshops made Ogles one of Southwest Florida’s most respected political analysts, and outlets like WWSB ABC 7 and WSRQ Sarasota have featured his insights. He can be reached at [email protected]


  • Richard Dickinson, MD

    March 9, 2021 at 11:21 am

    I am one of the partners of the telemedicine company, and wanted to inform you that we can complete the new COVID-19 Vaccine Determination of Extreme Vulnerability form (EO-21-47) for certain conditions. If someone has a condition that allows them to receive higher priority and be vaccinated during phase 1c, we can complete the form if proof of the medical condition is provided. There is a fee for the service.

    I understand many people do not have primary care physicians, or are unable to get a timely appointment with their physician to have this form completed. The link for this service is here:

    • Abby R

      March 13, 2021 at 1:46 am

      You are a hero among men – thank you SO much for sharing this!! I’ll be able to get the vaccine next week thanks to this service (and you) after scrambling for hours to figure out a way to get the letter signed last-minute. Sometimes reading the comments section actually pays off!

  • Dee

    March 14, 2021 at 9:46 am

    After we get the form signed, where do we send it?

Comments are closed.


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