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Health Services
Forms
Authorization to Disclose Medical Records
Authorization to Disclose Confidential Health Information. (Outgoing PHI)
Authorization to Obtain Medical Records
Authorization to Obtain Confidential Health Information. (Incoming PHI)
COVID-19 Pre-Visit Screening
Utilized to assess patients symptoms prior to an appointment. Upload form to your HaverHealth Portal within 24 hours of your scheduled appointment.
Travel Health Form
Should be printed, filled out, and brought to your appointment when receiving immunizations for travel.
Animal Lab Eligibility Clearance Forms
Matriculation Requirement Forms
Please do not call other departments on campus with Health Services related questions. The clinic is closed during summer but emails, voice mail, mail, and faxes are processed weekly.
All First Year Students
Instructions
- Register for the HaverHealth Portal. Note: To register for the Health Portal you must add two zeros (00) to the front of your Student ID, which can be found in the SER. All required health forms are located in your portal.
- Submit your Health Forms by the deadline of August 1.
Required Health Forms
A late fee of $75 will be charged for failure to submit your fully completed health forms by August 1.
Submit forms (A-G) through the HaverHealth Portal.
- Medical History, New Student Immunization History, and TB Screening
(Complete on-line in Portal.) - HIPAA Disclosure
(Print out and then submit your completed form via the Portal.) - Financial Responsibility
(Print out and then submit your completed form via the Portal.) - Physical Examination Form
(Print out and then submit your completed form via the Portal.) - Health Insurance Card
(Submit copy of card via the Portal.) - Consent to Treat a Minor
Required if you are under the age of 18 at time of arrival. - Sports Medical Clearance Requirements
- Special Diet Needs
For students with a medically-related dietary need, such as food allergies and needs associated with Crohns, Celiac or diabetes. Complete in the HaverHealth Portal.
Returning Students
Complete the HIPAA form, financial responsibility form, immunization medical form, and submit a copy of both sides of your health insurance card via the HaverHealth Portal.
All Haverford students are required to have proof of health insurance that is considered in-network within a ten mile radius of the campus.
International Students
All international students are required to purchase the College insurance plan.