Health Services Forms

Students younger than 18 years of age are required to have their Parent/Guardian sign these forms, as well as the student.

Although it is not required to have a physical exam prior to attending Bates, the following forms must be submitted by one of our approved methods as stated below before the July 1st deadline. The information you provide will be reviewed by Health Services staff and scanned into your secure Bates / CMMC electronic medical record. Your health information is confidential and cannot be released to anyone without your written consent.

Guidelines for helping you complete the required Health Forms.

Review the Health Forms FAQs if you have additional questions about the process.

There will be two roles to complete:
- For the “Student” Role, the Student’s name and Bates Email address should be entered.
- For the “Parent/Guardian” Role, the name of the Parent/Guardian and their associated email address should be entered.***The form will be sent to the email address used for the Parent/Guardian***
- The student can first fill in all the information in the form, sign it and it will be automatically sent to the Parent/Guardian’s email address.
- The Parent/Guardian can sign the form and it will be sent to Bates Health Services.

+Health History Section

**Health History Section**

1. When completing this section you will be asked for basic health related information. Below are some examples of the types of information required:
  - - Your Personal Contact Information
    - Parent/Guardian Contact Information
    - Emergency Contact Information for at least one person
    - Place of Birth
    - Bates Email Address
    - Family Medical history
    - Personal Medical history
    - Medications
    - Hospitalizations
  - - Checkout our FAQs for more information on what types of information you will need to complete this section.
  FAQs for Health Information

+Consent to Medical Treatment Section

**Consent to Medical Treatment Section**

This section only requires a signature.

+TB Assessment Section

**TB Assessment Section**

When completing this section, if you answer “No” to all three questions at the top of the form you can electronically sign and submit it. That’s all you need to do.
- However, if you answer “yes” to any of the first three questions you will need to have your healthcare provider fill out the TB Assessment form.
  - If you selected “yes” as noted above, there will be a viewable link you can click on to view/print the TB form and once your healthcare provider has completed their part you can send it to us by:
    Attach it Electronically to the online Upload TB Form under the Health Forms – Uploading Documents / Forms section:
    - Select “Upload TB Form” and attach your completed Signed TB form.
    - If you don’t have it electronically you can use your phone to take a snapshot of it and attach that to the online Upload TB Form.
    - Check out our “How To Attach the TB Form” video for further help.

Step 2: COVID-19 Vaccination Status Form / Vaccination Card

The next step involves completing the COVID-19 Vaccination Status Form and uploading a picture of your COVID-19 Vaccine Card.

Complete the COVID-19 Vaccination Status Form below.
Based which option you select regarding your current status, you can upload your COVID-19 Vaccination Card by attaching it to this form before submitting it.
1. 1. Attach it Electronically to the online “COVID-19 Vaccination Status Form below”.

Step 3: Immunization Form

The Final step involves completing the Immunization Form.

1. 1. This form requires both the Student and Parent/Guardian’s Signature on the printed form.
  2. You will first need to obtain a copy of your Immunizations from your healthcare provider.
  3. Once you have your immunization records you can send it to us by:
    1. Attach it Electronically to the online “Upload Immunization Form” under the “Health Forms – Uploading Documents / Forms section”:
      - Start a new Electronic Immunization Form online by using the link below and attach your Immunization records to the Form. Within the electronic form you will see an icon that you can select to upload your documents.
      - Check out our “How to Attach Immunization Records” video for further help.
      - Check out this example of the Immunization Records Form for additional help.
      - If you don’t have your immunization records electronically you can use your phone/device to take a snapshot/scan of it and attach that to the online Immunization Form.

Health Forms – Electronic Version

Steps

Required Form

Instructions

Health History, Consent to Medical Treatment and TB Form

- Place of Birth, Emergency Contact Information, Family Health History
- Personal Health History, Medications and Hospitalizations.
- Have you ever received treatment for latent TB?
Check out this example of the Health History, Consent to Medical Treatment, and TB Form
Check out our Step by Step Video Guide for additional help

COVID-19 Vaccination Status Form

Completing the COVID-19 Form is required. Bates College strongly urges all incoming students to be vaccinated for COVID-19. Students can demonstrate vaccinated status in either of the following ways:
provide proof of full vaccination and receipt of a recommended booster dose against COVID-19; or
provide proof of one dose of a COVID-19 vaccine since September 2022.

All students are required to report their COVID-19 vaccination status. Students will report their vaccination status by selecting one of the following on their first-year health forms:
proof of full vaccination and receipt of a recommended booster dose against COVID-19; or
proof of one dose of a COVID-19 vaccine since September 2022.
I am unable to receive recommended doses of the COVID-19 vaccine for medical reasons.
- (Receiving a medical exemption requires approval. For more information about medical exemptions please see below.)
I will not receive recommended doses of the COVID-19 vaccine for philosophical reasons.
I will not receive recommended doses of the COVID-19 vaccine for religious reasons.

Health Forms – Uploading Documents / Forms

Forms

Required Form

Instructions

Upload Immunizations Form

Please make sure to have your Immunizations form completed by your Primary Care Provider prior to completing this step.

Complete and sign the Electronic Immunization Form and use one of the two methods mentioned above for turning it in to Bates Health Services by July 1, 2023.

Acceptable proof of immunization includes: a copy of your high school immunization record or a copy of the original immunization certificate. Note: Only proof of vaccination or proof of immunity by blood titer are acceptable.

Please note the Immunization Form also includes recommended vaccines prior to your matriculation to Bates. We strongly recommend you receive these as well. Additional information regarding meningitis and college students is available from the Center for Disease Control and Prevention.

Upload TB Form

Here is where you can upload your TB form completed by your Primary Care Provider.
*Only required if you answered “yes” to any of the questions on the TB section of the “Health History, Consent to Medical Treatment and TB Form”.

Health Forms – Printable Version

Forms	Required Form	Instructions
1	Health History Form, Consent to Medical Treatment and TB Form	Complete and Sign – Please be sure to include any information about chronic illnesses, recent hospitalizations, allergies and medications.
2	Preliminary TB Assessment Form	Complete and submit the required TB Assessment Form. Print out the TB Form and once your healthcare provider has completed their part you can send it to us by one of two methods: Attach it Electronically to the online TB Form: Start a new TB Form online and attach your completed Signed TB form. If you don’t have it electronically you can use your phone to take a snapshot of it and attach that to the online TB Form. Check out our “How To Attach the TB Form” video for further help.
3	Immunizations Form	Complete and sign the Immunization Form Once you have your immunization records you can send it to us by one of two methods: Attach it Electronically to the online Immunization Form: Start a new Electronic Immunization Form online by using the link below and attach your Immunization records to the Form. Within the electronic form you will see an icon that you can select to upload your documents. Check out our “How to Attach Immunization Records” video for further help. If you don’t have your immunization records electronically you can use your phone/device to take a snapshot/scan of it and attach that to the online Immunization Form. You can also print the Immunization form, Sign it and Mail it to Health Services:Mail to: Bates Health Services 31 Campus Ave. Lewiston, ME 04240 Acceptable proof of immunization includes: a copy of your high school immunization record or a copy of the original immunization certificate. Note: Only proof of vaccination or proof of immunity by blood titer are acceptable. Please note the Immunization Form also includes recommended vaccines prior to your matriculation to Bates. We strongly recommend you receive these as well. Additional information regarding meningitis and college students is available from the Center for Disease Control and Prevention.

Mandatory Health Insurance

Bates College requires that all students verify they have their own health insurance coverage by August 26th or be automatically enrolled in the Bates Student Health Insurance Plan.

All Domestic students enrolled in 3 or more classes are eligible and are required to enroll or decline the Bates College Student Health Insurance Plan through their Garnet Gateway account. Students who have not made a selection by August 26, 2023 will be billed for the coverage and will be automatically enrolled.

All International students & Scholars will automatically be enrolled in and billed for the Bates College Student Health Insurance Plan.
As a college student responsible for your own health decisions, you will be primarily responsible for managing your insurance claims while you are here. To do so, it is essential to understand your policy and the specifics included within it; you may want to contact your insurance company and update them that your temporary residence will be located in Maine at Bates College. More information about insurance requirements for all students can be found here.

More information about financial aid and affording the cost of the Bates Student Health Insurance Plan can be found here.

We would also like to remind you to bring your health insurance card to all health related appointments at Bates Health Services to ensure access to care. Bates Health Services bills students’ health insurance.

We look forward to your arrival on campus this August. We are happy to answer questions about these requirements. Please contact us either by email, healthservices@bates.edu, or by calling 207-786-6199.