Middlebury Handbook

Health Forms

Commitment to Confidentiality

Vaccines

Emergency Preparedness: Required Evacuation Plan

Records Retention Policy

Center for Health and Wellness

The Center for Health and Wellness supports the learning environment of Middlebury’s vibrant and diverse academic community by providing readily accessible and confidential health care to students within an inclusive, collaborative, and integrated treatment framework. Our multi-disciplinary staff are here to work with students and make referrals to community resources as needed.

We strive to create a safe, affirming, and nonjudgmental environment that embraces human diversity, including race, color, ethnicity, national origin, religion, sex, sexual orientation, gender identity and expression, age, marital status, place of birth, and disability status. We are committed to respecting the uniqueness and complexity of student identities and life experiences.

1. Required Health Forms

The following forms and documents are required and must be completed and/or uploaded to the student health portal prior to arrival on campus for all new undergraduate students. Students who do not comply with these essential expectations may not be granted access to their housing.

To be completed in the student health portal:

1. Health History Form
2. Confidentiality and Consent to Treat Form
3. Emergency Contacts Form
4. Tuberculosis Screening

To be uploaded to the student health portal:

1. Images of the front and back of your insurance cards including primary, secondary, dental, and pharmacy if you have separate policies
2. A copy of your immunization record(s) provided to you by your health care provider(s)
3. The Athlete Physical Exam Form (required within 6 months of start of season for students participating in intercollegiate sports, club rugby or club crew)

The following forms and documents are conditionally required and must be completed and/or uploaded to the student health portal prior to arrival on campus for all new undergraduate students for whom they apply:

1. Consent Form for Treatment of a Minor for students who will arrive on campus under the age of 18
2. Physician TB Form for students who are determined to be at risk for tuberculosis based on the Tuberculosis Screening form in the student health portal
3. Provisional Admittance Form for students who will not be in compliance with Vermont regulations for immunizations by their matriculation deadline

The following forms and documents are recommended to aid in the provision of comprehensive services and should be uploaded to the student health portal prior to arrival on campus for new undergraduate students:

1. Physical Examination Form

Forms and documents are due:

• June 15 for September matriculation
• November 15 for February matriculation

First-time student athletes are also required to meet conditions and complete forms listed in the First-Time Athlete Athletic Clearance Procedures.

All required forms and instructions are available on the student health portal under “My Forms” or the Center for Health and Wellness’s Forms website.

2. Commitment to Confidentiality

a. Understanding Your Health Record/Information

Each time you receive services from the Center for Health and Wellness offices (Counseling, Health Services, Health and Wellness Education, Integrated Care and Sports Medicine), our care partners, or when staff have an interaction with another health care provider about you, the information is documented in a secured, password protected electronic health record that is accessible only to Center for Health and Wellness staff (and as necessary for health care operations on a confidential basis). Typically, this record contains a summary of your presenting concerns and symptoms, physical exam and/or other intake information, test results, diagnoses, progress notes, treatment summaries, referrals to other resources, participation in an intervention or program, and plans for future courses of treatment if appropriate. This information makes up your health record or personal health information, and serves as a:

• Basis for planning your care and treatment;
• Means of communication with other health professionals who contribute to your care;
• Legal document describing the care you received;
• Source of information for public health officials charged with protecting the health of this state and the nation (only under very restricted circumstances);
• Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Your health record at Middlebury may also contain information from other healthcare providers that you share with us or ask them to share with us. Any physical records and all digital contents are owned by Middlebury and its health care providers. As a patient, you are entitled to access your health records at all times through the student health portal and/or you may request that we prepare a summary for you. You may download, print, or save components or the entirety of your health record at Middlebury through the student health portal at any time. You may also request printed records or summaries by emailing chw@middlebury.edu. Center for Health and Wellness staff are available to review your records with you by making an appointment during business hours.

i. Our Commitment to Confidentiality

Health records at the Center for Health and Wellness are confidential and are kept separate from all other College records that may be created during your time as an enrolled student. Center for Health and Wellness staff confer with one another as needed to provide integrated care for you. We also work with Porter Hospital, the Counseling Service of Addison County (CSAC), and our telehealth partner TimelyCare to ensure a wide range of medical and mental health options for students. When students receive treatment from multiple providers, in multiple locations, or with community providers, we exchange only such information as is needed to maintain continuity of care. Students may make requests to the Center for Health and Wellness, Porter Hospital ,or CSAC to revoke or restrict authorization to share such information.

Students may authorize sharing of information to third parties such as family members, health care facilities, or in other circumstances and they have the right to revoke that authorization after signing. Middlebury will not release any information about you to third parties without your authorization, except under the following conditions:

• As authorized or required by law (i.e., when we are presented with a valid court order requiring us to release records);
• As necessary to protect you or others from an imminent threat to health and safety, or to protect property from a serious threat of damage;
• As necessary to notify parents, emergency contacts, and/or College officials when you have a serious mental or physical health problem and are unable or unwilling to assume responsibility for notifying others;
• Under some circumstances when legal guardians may have the right to access the records of a minor.

Middlebury’s Confidentiality and Consent to Treat Form includes consent for Center for Health and Wellness staff to share personal health information with important community partners to ensure high-quality, informed care for students. These partners include Porter Medical Center, the Counseling Service of Addison County, and our telehealth partner TimelyCare.

Middlebury College and the Center for Health and Wellness are not subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and therefore are not required to comply with the various federal regulations relating to the use and disclosure of health information. Middlebury College and the Center for Health and Wellness are, however, subject to the Family Education Rights Protection Act of 1974 (FERPA) which classifies your health records as treatment records and confers similar protections related to privacy.

This policy should not be interpreted as creating any contractual rights and Middlebury College reserves the right to make changes to this policy at any time without prior notice. 

ii. Treatment of Minors

According to certain provisions of Vermont State law, legal guardians must provide permission for some forms of healthcare for individuals under the age of 18 (minors). These provisions also allow for certain exceptions. In these situations, a legal guardian’s permission is not required:

• Minors of any age will be cared for in emergency situations that necessitate immediate treatment;
• Minors of any age may receive outpatient mental health counseling without consent of a  guardian, but not prescription medications;
• Minors 12 years of age and older may obtain treatment for sexually transmitted diseases, substance dependence and  abuse;
• If a minor requires hospitalization for treatment of sexually transmitted diseases, substance dependence, or  abuse, the  legal guardians must be notified of the hospitalization;
• Minors of any age may obtain treatment for the termination of a pregnancy, or receive medical treatment necessary to obtain contraceptive devices and medications;
• Minors of any age may obtain medical treatment related to rape, incest, or sexual abuse. Health care providers are required to report such incidents to the Department of Children and Families within 24 hours;
• Minors 14 years or older may voluntarily admit themselves to a hospital for mental health related treatment if they give informed consent in writing;
• Minors under 14 may admit themselves to a hospital for mental health related treatment by providing their own written informed consent and a written application from a parent or guardian;
• Minors who are married or have ever been married, minors on active U.S. military duty, and minors emancipated by court order may give informed consent to their own health care.

Center for Health and Wellness staff are available to provide an initial consultation with students who are under 18 years of age to review the need(s) for guardian consent for treatment(s) as stipulated by Vermont State law.

If you will be under the age of 18 when you arrive on campus, your parent and/or guardian will need to print, complete, and return the Consent to Treat a Minor Form available on the Forms page of the Center for Health and Wellness website.

Additionally, minors arriving on campus will need to set up parent or guardian-approved accounts to access telehealth through our partner TimelyCare. Students must call 1-833-484-5369 with a parent or guardian on the same line or conferenced in to create a minor account. Until the student turns 18, both the student and guardian will be given access to the account to view upcoming appointments, treatment summaries, and any engagement with self-guided content in the application. Upon turning 18, students will be able to access TimelyCare with a private account through their single sign-on credentials.

Insurance Coverage and Requirements

Middlebury College requires enrolled undergraduates to have sufficient health insurance coverage that meets the standards set by the state of Vermont. New students are required to upload copies of their health insurance card(s) as a part of the on-boarding process in their student health portal. While the Center for Health and Wellness does not bill for services, we can share the insurance information you have uploaded with outside providers at your request.

 Middlebury provides, as a part of the comprehensive fee, three insurance coverages for students:

• All full-time students during the academic year have a $5,000 accident policy.
• Participants in club sports have an additional layer of coverage.
• Participants in varsity sports have a second layer provided by the College and a third layer provided by the NCAA.

Limits to Care for the Center for Health and Wellness and the State of Vermont

While we provide comprehensive care tailored for Middlebury students' needs, there are limits to the scope of our services and resources that students should be aware of. Some examples of health care needs that may be outside our scope include, but are not limited to:

• Students consistently need services more than once a week or after-hours, or whose situation cannot be stabilized with short-term crisis intervention.
• Situations where the recommended level of care is for an intensive outpatient program, partial hospitalization, inpatient, or residential programs, which are incompatible with Middlebury’s enrollment requirements.
• Students who are unable to safely possess and/or administer medications independently
• Recent or multiple hospitalizations
• Chronic thoughts of suicide or history of repeated suicide attempts
• Diagnosis or assessed clinical needs that require regular long term treatment and intervention
• Evidence or risk of progressive deterioration in mental or emotional functioning that requires intensive intervention
• Students who are unable to partner in their own healthcare, including utilizing established safety plans and/or engaging with recommended care within and outside of the Center
• Specialized treatment not within the scope of our providers

Center for Health and Wellness staff can make referrals to specialists and intensive care options when indicated, but we cannot guarantee appointment availability, treatment, placement or admittance into any hospitals or programs in Vermont or out of state.

Students coming to Middlebury with chronic conditions, interdisciplinary treatment teams, or known needs for frequent specialty services should have proactive conversations with their home-based providers to understand if there are any limits to their ability to provide continuous care. Center for Health and Wellness staff are available to coordinate and create plans for care transition or supplementation with home providers before arrival on campus including evaluations of whether care plans are in scope for the offices within the Center. Please contact the appropriate Center for Health and Wellness office or email chw@middlebury.edu to start the process as early as possible to avoid gaps in care.

Financial Responsibility and Opportunities for Assistance

Students who consent to off-campus referrals and/or the receipt of laboratory testing, imaging, prescriptions, or other kinds of care not provided at the Center for Health and Wellness offices assume the financial responsibility or commit to negotiating satisfactory arrangements with the organization or provider. This includes contracted or consulting healthcare providers who may work under agreements with the Center for Health and Wellness to provide services to students on or off campus.

Center for Health and Wellness staff can help direct students to campus resources and funding sources that may be able to assist with healthcare costs in addition to payment plan offerings for community providers who make them available to patients. Financial assistance from the Center for Health and Wellness is limited to students who qualify for the use of substance use treatment and neurodiversity funds.

iii. Questions and Grievance Process

If you have concerns, needs, or questions that were not (or could not be) addressed by staff members directly involved in your care, you may contact the Associate Vice President for Student Health and Well-being at 802-443-5361 or bmccall@middlebury.edu. You may also contact the Vice President of Student Affairs at 802-443-2465 or sruzicka@middlebury.edu.

Most professions in the Center for Health and Wellness are also governed by laws and/or professional organizations that define a scope of practice, professional conduct and/or codes of ethics. Healthcare consumers who have inquiries can obtain a form to register a complaint with the State of Vermont and can also call 802-828-1505 or contact:

Secretary of State’s Office
89 Main Street, 3rd Floor
Montpelier, VT 05620-3402

3. Vaccines

a. Required Vaccines under Vermont Law

In order to remain enrolled as a residential undergraduate student, Vermont law requires that all students submit an up-to-date immunization record, including proof of vaccination or positive titers (when applicable) for:

• Measles, Mumps, and Rubella
• Meningitis
• Hepatitis B
• Tetanus, Diphtheria, and Pertussis
• Varicella

 b. Medical and Religious Exemptions

If you have any religious or medical exemptions, please complete the Vermont College Immunizations Exemptions Form as applicable and upload to your student health portal as an Immunization Exemption.

Please be advised that unvaccinated students with exemptions may be asked to miss class or leave campus at their own expense in the event of a communicable disease outbreak. Unvaccinated students who are not actively engaged in a vaccination plan or have not submitted exemptions may be placed on involuntary leaves.

c. Recommended Vaccines for Global Travel

Some students, including those who travel abroad, will benefit from:

• Hepatitis A vaccine series
• Typhoid vaccine

Other travel vaccines depend on destination and can be determined at a travel visit with Health Services.

Due to the length of time some vaccine series require, it is recommended that all students considering travel abroad also consider receiving the Hepatitis A vaccine series prior to matriculation.

4. Required Personal Departure Plan in the Case of Evacuation or Emergency

Because of the potential need for a quick departure from campus related to a personal, family, or community emergency or in response to an outbreak of communicable illness, all Middlebury College students are required to develop a personal departure plan for emergencies and/or situations that require evacuation, submit it to their program,  and update it on an annual basis.

Undergraduate students are required to submit their plan through Banner. Students should consider and plan for the following as a part of their personal departure plans:

• Any currently known reasons an emergency departure may be necessary (e.g. vaccination exemptions for communicable diseases, prior history of emergency departures, health conditions, family needs, etc.)
• Primary and secondary safe locations to which a student could return
• Travel plans for each identified location including mode of transportation (i.e. vehicle, bus, train, plane)
• Cost considerations for the identified travel plans
• An identified person (who may or may not also be listed as an emergency contact in Banner) who could accompany you to travel if you are unable to safely do so on your own in an emergency including a contact phone number, physical/mailing address, and email address.

Students should alert any family members, friends, or trusted acquaintances that are a part of their plan at the time of submission and annual review. In situations where students may need to enact their departure plan or where review is required by College officials, persons identified in the plan may be contacted by the College to verify their participation in the plan. Students may not be allowed to attend classes, register for classes, or otherwise fully participate in their program until they have provided a plan that meets the minimum required elements as stated within each program.

5. Records Retention Policy

The Center for Health and Wellness, in order to establish guidelines for the maintenance, retention, preservation and disposal of medical records that are created or maintained by it, hereby adopts the following policy for preserving those records.

Policy

The Center for Health and Wellness engages in the following actions in order to appropriately maintain, retain, preserve and purge treatment:

• retain treatment records for the period of time required by applicable law and regulation as indicated in these guidelines;
• purge of treatment records promptly, in the appropriate manner after they have satisfied their required retention period, unless they are the subject of a Litigation Hold;
• preserve treatment records subject to a Litigation Hold, if the records would otherwise be purged.

Retention Guidelines

Treatment records are to be retained for the time periods indicated as follows.  The medical records may be maintained in paper or electronic format, as appropriate and may be stored on-site or off-site, in accordance with the need to access the records.  The creator or receiver of the medical records is responsible for retaining the record.

RECORDS	RETENTION PERIOD
Treatment records - Adults (over 18)	7 years from last date of treatment or graduation, whichever is the latter.
Treatment records – Minors (under 18)	The longer of 7 years from last date of treatment, graduation, or until the patient is 25, whichever is the latter

Former students who have graduated from Middlebury or otherwise departed from the community who would like to request a copy of their records should email chw@middlebury.edu and include their name, date of birth, and Middlebury ID number.

Some records are not subject to any retention period and can be discarded when they do not have administrative value.  Other documents are not considered “records” within the meaning of this policy and need to be maintained only as long they have administrative value.  Documents that are not considered “records” include: duplicate copies of correspondence or other documents, blank forms, and transitory messages used for informal communication of information only, such as voice mails, and self-sticking notes.  Documents that are not “records” may be discarded when they do not have administrative value.

Purging Guidelines

Records should be purged promptly if they do not need to be retained in accordance with these guidelines.   Records must be disposed of in a manner that safeguards confidential, sensitive or proprietary information contained in the records. Ordinarily, physical records will be securely shredded and disposed of while electronic records will be purged from the electronic health record.

Litigation Hold Guidelines

The Associate Vice President for Student Health and Well-Being shall be notified immediately if an employee receives notification of any claim or complaint that could lead to litigation or governmental investigation.  The Associate Vice President for Student Health and Well-Being will evaluate the information and communicate with the appropriate employees to assure that all evidence and records relating to the matter are preserved until the litigation or investigation is complete.   No employee should discard any document subject to a Litigation Hold.