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 checklist 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).
It is imperative that we receive all completed forms no later than January 15, 2015. If your health file is not complete, you will not be able to register for courses when you arrive on campus!
Required Insurance Information
Please send us a photocopy of both sides of your health insurance I.D. card and pharmacy benefit I.D. card (if you have waived the Amherst College Student Injury and Sickness Insurance Plan) by email or fax (413-542-2647) no later than July 5, 2014.
Required Health Forms
- 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). Massachusetts law requires up-to-date immunizations.
- Health History Form Please provide the requested information.
- Learning and Accommodation Assessment Forms Please read and complete.
- Email Consent Form Please read and complete.
- Notice of Privacy Practices Please read and complete.
Chickenpox (Varicella) Note: For new Students who have had or believe to have had Chickenpox(Varicella). The following paperwork is needed:
- Provide history of the disease through documentation from your liscensed medical professional or
- Have your medical professional administer a blood test (titer) confirming immunity.
- Physical Examination Athletes must have this examination form 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 three months of your arrival at Amherst.
- Pre-participation Health History Form Athletes must complete and return this form with their other health forms.
- Sickle Cell Form 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.
- In addition:
- 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.
Advance Directive Form is a legal document that protect your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself. The forms posted here are valid in Massachusetts, when completed by a competent adult at least 18 years old.
This form is not required.
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.