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COVID-19 Vaccine Eligibility Letter Request

NOTE: THIS FORM IS FOR ELIGIBILITY LETTERS. THIS IS NOT FOR REQUESTING A COVID-19 VACCINE.

New York State is now offering non-physician offices COVID-19 vaccines for distribution per New York State guidelines. Please note that Middletown Medical still does not have access to the vaccine. The “Am I Eligible?” app is the best way to see all available appointments at New York State-run vaccination sites: https://am-i-eligible.covid19vaccine.health.ny.gov/ Beginning February 15, 2021, adult New Yorkers of any age with the following conditions qualify for the vaccine:

  • Cancer (current or in remission, including 9/11-related cancers)
  • Chronic kidney disease
  • Pulmonary Disease, including but not limited to, COPD (chronic obstructive pulmonary disease), asthma (moderate-to-severe), pulmonary fibrosis, cystic fibrosis, and 9/11 related pulmonary diseases
  • Intellectual and Developmental Disabilities including Down Syndrome
  • Heart conditions, including but not limited to heart failure, coronary artery disease, cardiomyopathies, or hypertension (high blood pressure)
  • Immunocompromised state (weakened immune system) including but not limited to solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, use of other immune weakening medicines, or other causes
  • Severe Obesity (BMI 40 kg/m2), Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
  • Pregnancy
  • Sickle cell disease or Thalassemia
  • Type 1 or 2 diabetes mellitus
  • Cerebrovascular disease (affects blood vessels and blood supply to the brain)
  • Neurologic conditions including but not limited to Alzheimer’s Disease or dementia
  • Liver disease

The list is subject to change as additional scientific evidence is published and as New York State obtains and analyzes additional state-specific data. If you are in need of a letter from your provider to prove your eligibility within the above categories, please fill out the request form below.

COVID-19 Vaccine Eligibility Letter Request

NOTE: THIS FORM IS FOR ELIGIBILITY LETTERS. THIS IS NOT FOR REQUESTING A COVID-19 VACCINE.

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