HEALTH INSURANCE ENROLLMENT/WAIVER FORM
ALL students are enrolled in and billed the $753.00 Premium for the Pine Manor College Student Health Insurance Plan for the 2008-2009 academic year. This is done automatically, as mandated by Massachusetts Law. However, students may waive participation in the College Student Health Insurance Plan and receive credit for the $753.00 by documenting that they have comparable coverage under another plan. To have this charge removed from your account, you must complete the on-line Insurance Enrollment/Waiver Form.
HEALTH REPORT FORM The deadline for submission is August 17, 2007 (for Fall Semester) or January 4, 2008 (for Spring Semester). If you enroll after the deadline, your completed form must be submitted no later than September 7, 2007. Failure to submit the completed Health Report Form by September 7th will result in a $50.00 late fee.Please bring a copy of your completed HEALTH REPORT FORM with you. Documents have been lost in the mail and your copy of your medical records will ensure that your enrollment process will not be delayed.
MEASLES: Two doses of measles vaccine or MMR given at least one month apart and on or after 1st birthday
MUMPS: One dose of mumps vaccine or MMR given on or after 1st birthday.
(Please note: Due to recent outbreaks of mumps disease, all students should have documentation of TWO doses of MMR vaccine OR serologic evidence of immunity)
RUBELLA: One dose of rubella vaccine or MMR given on or after 1st birthday.
HEPATITIS B: Three doses of Hepatitis B vaccine; 2nd dose given 1-2 months after 1st; 3rd dose 4 -6 months after 1st. OR: A report documenting a positive immune titers for the above diseases (titer values and interpretation must be included).
TETANUS/ DIPHTHERIA vaccine (Td) or Tdap booster within the past 10 years
VARICELLA VACCINE (chickenpox): Two doses one month apart recommended if no history of disease.
HUMAN PAPILLOMAVIRUS (HPV) VACCINE: Three doses at 0, 2 and 6 month intervals.
TUBERCULOSIS SCREENING All students must complete and return the Tuberculosis Risk Assessment Questionnaire (RAQ) and, if deemed to be at risk, a tuberculosis skin test (Mantoux / PPD), administered within the past 6 months, is required. History of prior BCG vaccine does not exempt testing. The test must be checked by a healthcare provider within 48-72 hours of being administered AND the result, in millimeters, must be recorded. If PPD is positive, a report of chest X-ray, taken within the past 6 months, is required. If you have been or are currently being treated for a positive PPD, please include beginning and end dates of treatment with INH (or if other medication, please specify).
PHYSICAL EXAMINATION A physical examination within the past six months is required. If you have chronic health problems (like asthma or diabetes) bring a health summary from your healthcare provider. This helps the Health Services staff to provide you with the best possible care once you arrive on campus. If you have ongoing health needs, we suggest that once you arrive on campus you make an appointment to meet with our providers to discuss your care. Call (617) 731-7171 for an appointment.
POTENTIAL ATHLETES:Students are NOT eligible to practice or participate in intercollegiate sports until the Health Report Form, including a physical examination, clearance to participate and immunizations documentation, has been completed and submitted to Health Services.
PRESCRIPTIONS
Bring enough of your ongoing medications for the first month of school and bring a copy of the prescriptions with you. Plan ahead for refills. If you wear eyeglasses or contacts, bring a copy of your prescription with you.
