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 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.

Health History & Insurance, Consent to Medical Treatment, and TB Form

  1. 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.
  2. *Verify Your Email Address
    • When you start filling out this form you will be asked to verify your email address
    • A security code will be sent to the email address you provide when you initially start the process.
    • The security code, or link that is also included in the email, will allow you to continue to edit your form.

+Health History & Insurance Section
**Health History & Insurance Section**

  1. When completing this section you will be asked for basic health related information.
    • If you are deciding to waive Bates Health Insurance you will also need a copy of your parent / guardian’s insurance card.
    • You can send it to us by one of two methods:
      1. Attach it Electronically to the online Upload Insurance Card Form:

        • Select the Uploading Insurance Card Form online by using the link below (Health Services – Uploading Documents / Forms section) and attach a picture of your insurance card to the Form. Within the electronic form you will see an icon that you can select to upload your documents.

        Bring it with you in-person to:
        Bates Health Services
        31 Campus Ave.
        Lewiston, ME 04240

  • 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**

  1. This section only requires a signature.


+TB Assessment Section
**TB Assessment Section**

  1. 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 one of two methods:
        1. Attach it Electronically to the online TB Form:
        2. You can also Mail it to Health Services:
            Mail to:
            Bates Health Services
            31 Campus Ave.
            Lewiston, ME 04240


Step 2: Immunization Form

Immunization Form

The Final step involves completing the Immunization Form.

  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 one of two methods:
    1. 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.
    2. You can also Mail it to Health Services:
        Mail to:
        Bates Health Services
        31 Campus Ave.
        Lewiston, ME 04240

Health Forms – Electronic Version


Steps
Required Form
Instructions
1
Health History, Consent to Medical Treatment and TB Form

2
Immunization Form
Complete and sign the Immunization Form and and use on of the two methods mentioned above for turning it in to Bates Health Services by July 1, 2018.

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.

Health Forms – Uploading Documents / Forms

Forms
Required Form
Instructions
1
Upload Immunizations Form
Here is where you can upload your Immunizations form completed by your Primary Care Provider.
2
Upload TB Form
Here is where you can upload your TB form completed by your Primary Care Provider.
3
Upload Health Insurance Card Picture
Here is where you can upload a picture of your Health Insurance Card. Please include a picture of both front and back.

Health Forms – Printable Version

Forms
Required Form
Instructions
1
Health History Form
Complete and Sign – Please be sure to include any information about chronic illnesses, recent hospitalizations, allergies and medications.
2
Consent to Medical Treatment Form
Complete and Sign
3
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:
  1. Attach it Electronically to the online TB Form:
  2. You can also print this TB Form, Sign it and Mail it to Health Services:
      Mail to:
      Bates Health Services
      31 Campus Ave.
      Lewiston, ME 04240

4
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:
  1. 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.
  2. 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 July 30th or be automatically enrolled in the Bates 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. We would also like to remind you to always have your insurance/prescription cards on hand and bring them with you to all health related appointments at Bates Health Services to ensure access to care.

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 June 30, 2019 will be billed for the coverage and will have until July 30, 2019 to have the charge removed by declining coverage. After July 30, 2019 any student who has not declined the insurance will automatically be enrolled.

All International students & Scholars will automatically be enrolled in and billed for the Bates College Student Health Insurance Plan. Please note that students awarded fee-based financial aid from Bates College will receive an additional grant to offset 100% of the insurance cost.

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.