Required Health Forms
Dear New Amherst Students and Families,
Welcome to Amherst College. As an Amherst student, you will be eligible to use the Health Center throughout the academic year. Please feel free to contact us or make an appointment to discuss any health concerns while you are at Amherst. We need to receive certain information from you in order to provide appropriate health care when necessary, to promote the goals of the College, and to comply with state law and regulations. Please refer to the check list below in order to submit all of the necessary completed information. Forms may be returned by mail (Amherst College, Health Services, Box 5000, Amherst, MA 01002), fax (413-542-2647), or email attachment (email@example.com), or in person. It is imperative that we receive forms no later than January 17. If your health file is not complete, you will not be able to register for courses when you arrive on campus!
1. Physical Examination completed by a licensed medical provider (physician, PA, or nurse practitioner) who is a not a family member. The examination must have been performed within twelve months of your arrival at Amherst.
2. Health History Form please provide the requested information.
3. New Student Immunization Form must be completed by your medical provider. If immunization status is unknown or incomplete, obtain an antibody titer for measles, mumps, rubella, Hepatitis B, and varicella or arrange for re-immunization (as outlined on the attached Immunization Form) when you receive the required physical examination from your medical provider. Massachusetts law requires up-to-date immunizations.
4. Learning and Accommodation Assessment Form Learning and Accomadation Assessment Form- read and complete.
5. Email consent form Email consent form —read and complete.
6. Notice of Privacy Practices Notice of Privacy Practices-—read and complete.
7. INSURANCE INFORMATION— Complete all of the forms listed above. Return all forms above and a photocopy of both sides of your health insurance I.D. card (if you have waived the Amherst College Student Injury and Sickness Insurance Plan) by mail or fax (413-542-2647) no later than Friday, January 17.
- If you will be a varsity athlete at Amherst College, ask your medical provider to order a screening test for “sickle cell trait.” This is a new NCAA requirement.
- If you intend to participate in sports and have recently sustained a serious injury or have undergone related surgery, enclose an operative report and a treatment plan for rehabilitation.
- If you are currently under medical treatment, enclose a summary of the medical evaluation and treatment plan.
- If you have had recent injuries or operations (within the last year), enclose a medical report which includes any applicable restrictions or limitations.
Thank you for your assistance in meeting these college requirements. If you have any questions regarding these forms, please contact the Keefe Health Center’s Office at 413-542-2267 or firstname.lastname@example.org.
Warren Morgan, M.D.