provider packet - sites.rowan.edu · tb (tuberculosis) evaluation & testing form page 6 of 7...

Rowan University ⦁ Student Health Services ⦁ Winans Hall ⦁ 201 Mullica Hill Road ⦁ Glassboro, NJ 08028 856.256.4333 (phone) ⦁ [email protected] (email) ⦁ www.rowan.edu/health

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Provider Packet

Due Dates:

Incoming Fall Students – July 15th

Incoming Spring Students – December 15th

Incoming Summer Students – July 15th

Important Reminders: Students should carry health insurance & prescription cards with them at all times. Review your current health insurance plan and follow steps to purchase or waive Rowan

sponsored insurance annually. Check the Rowan Student Email account frequently for important notices.

Online Health Forms: Complete all three of your online health forms through our Online Wellness Link (OWL).

Provider Packet: Print your packet and schedule an appointment to have your healthcare provider to complete it. Upload your completed packet into our Online Wellness Link (OWL).

Online Modules (Freshmen Only): Complete all Alcohol Wise and Consent & Respect Modules modules. 3

PLEASE READ CAREFULLY: THESE FOLLOWING ARE REQUIRED BY NJ STATE LAW AND ROWAN UNIVERSITY POLICY. FAILURE TO COMPLETE THE FOLLOWING 3 STEPS MAY RESULT IN UP TO $100 IN LATE FEES & A HOLD PLACED ON YOUR ACCOUNT, PREVENTING FUTURE REGISTRATION.

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IMPORTANT NOTICE TO RE-ADMITT STUDENTS: If you previously submitted health forms you must contact the front office to have them

pulled from our archives. Records are saved for 10 years before being destroyed.

http://www.rowan.edu/health


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Wellness Center Requirements

STEP 1: Online Health Forms

A. Go to https://studenthealth.rowan.edu to access the Online Wellness Link (OWL). (If don’t know your network username and/or password visit https://irt.rowan.edu/starting/students/students.html.) Select Wellness Center Requirements from the menu across the top. Complete and submit each of the three forms:

Personal Information Form Personal & Family Health History Form Meningitis Information Form

B. Check Yourself: You should notice a “submit date” next to each form once they have been completed. C. Scroll down to the bottom of the Wellness Center Requirements page. Under the “Additional Wellness Center

Requirements” heading click on the Provider Packet and print the packet.

STEP 2: Provider Packet

A. Put your name, date of birth, and student ID# on all forms and then complete the TB Screening Form (page 5) prior to appointment.

B. Schedule a physical exam appointment with your healthcare provider to complete the packet. If you have had a physical, within 12 months of the first day of classes, have your healthcare provider complete the packet based on that exam. Be sure to talk to your provider about any chronic conditions you may have and how you can be prepare to deal with these conditions when you are at school.

C. Once your healthcare provider has completed the packet look it over to make sure all required forms are complete, signed, and dated where indicated. Then scan and save your documents into separate files in the categories listed below. Save your files in one of the following file types: .gif, .png, .tiff, .tif, .jpg, .jpeg, .txt or .pdf. Do not use any numbers or special characters in your file name.

Immunization Record – Provider Packet Page 3 and any additional immunization forms Entrance Physical Form – Provider Packet Page 4 TB Screening Form – Provider Packet Page 5 (ALL questions must be answered) TB Evaluation and Testing Form – Provider Packet Page 6 Consent for Treatment – Provider Packet Page 7 Titer Lab Reports/ Other Labs – Any other required titers, labs and/or radiologist’s reports

D. Go to https://studenthealth.rowan.edu to access the Online Wellness Link (OWL). After logging in, select the Upload tab from the menu and follow the instructions provided for uploading your documents.

STEP 3: Online Modules – FRESHMEN ONLY

A. Go to https://studenthealth.rowan.edu Select Wellness Center Requirements from the menu. Scroll down the page and select the Online Modules link located under the “Additional Wellness Center Requirements” heading. Complete the Alcohol-Wise and Consent & Respect modules with a passing grade of at least 75%.

B. 30 days after completing the initial Alcohol-Wise and Consent & Respect you are required to take a brief follow-up Alcohol Wise module.

Need Help? Visit www.rowan.edu/healthforms for more information.

Due Dates:

Incoming Fall Students – July 15th

Incoming Spring Students – December 15th

Incoming Summer Students – July 15th

https://studenthealth.rowan.edu/

https://irt.rowan.edu/starting/students/students.html



http://www.rowan.edu/healthforms

Immunization Form of 7


Due Dates: Incoming Fall & Summer Students – July 15th, Incoming Spring Students – December 15th

Last Name First Name M.I. Date of Birth: M/D/Y Banner ID#

IMMUNIZATIONS REQUIRED FOR:

MEASLES, MUMPS, RUBELLA (MMR) – 2 doses of vaccine administered after 1968, on or after 12 months of age, and at least 28 days apart are required OR laboratory proof of immunity. Copy of Measles (Rubeola), Mumps, and Rubella Virus IgG Antibody laboratory titer report must be attached if submitting in lieu of immunization dates. EQUIVICAL RESULTS NOT ACCEPTABLE.

■ ALL STUDENTS Born AFTER 1956

MMR Dose 1: ____/____/____

OR

MEASLES : Dose 1: ____/____/____ Dose 2: ____/____/____

OR

MUST ATTACH MEASLES IgG Titer Lab Report showing immunity

MUMPS : Dose 1: ____/____/____ Dose 2: ____/____/____

MUST ATTACH MUMPS IgG Titer Lab Report showing immunity

MMR Dose 2: ____/____/____ RUBELLA : Dose 1: ____/____/____ Dose 2: ____/____/____

MUST ATTACH RUBELLA IgG Titer Lab Report showing immunity

HEPATITIS B - In lieu of immunization dates a copy of a Hepatitis B laboratory titer report showing evidence of immunity may be submitted.

■ SELECT START

■ ALL FULL-TIME STUDENTS - taking 12 or more credit hours ■ ALL ATHLETES

HEPATITIS B vaccine

Dose 1: ____/____/____

Dose 2: ____/____/____

Dose 3: ____/____/____

HEPATITIS B vaccine – two dose regimen administered at age 11-15 years of age.

Dose 1: ____/____/____

Dose 2: ____/____/____

HEPATITIS A and B combined

Dose 1: ____/____/___ Dose 2: ____/____/____

Dose 3: ____/____/___

MUST ATTACH HEPATITS B IgG Titer Lab Report showing immunity

MENINGOCOCCAL MENINGITIS VACCINATION – administered on or after 16th birthday or within 5 years of the start of classes. Must include Groups A, C, Y, W-135. BOOSTER DOSE required if meningococcal vaccination administered more than 5 years prior to the start of classes.

■ ALL STUDENTS RESIDING IN CAMPUS HOUSING – must be received prior to move-in ■ ALL ATHLETES & ASCEND

MENINGOCOCCAL of A, C, Y,W-135

Dose 1: ____/____/____

Dose 2: ____/____/____

TETANUS – Booster in the last 10 years. ■ ALL ATHLETES

Tdap

Dose : ____/____/____

Td

Dose : ____/____/____

TT

Dose : ____/____/____

In addition to the above immunizations the following are highly recommended. HPV

Dose 1: ____/____/____

Dose 2: ____/____/____

Dose 3: ____/____/____

Varicella Dose 1: ____/____/____

Dose 2: ____/____/____

Hepatitis A Dose 1: ____/____/____

Dose 2: ____/____/____

Pneumococcal

Dose : ____/____/____

Meningococcal B Dose 1: ____/____/____

Dose 2: ____/____/____

Dose 3: ____/____/____ MUST BE SIGNED & DATED

Physician/PA/NP Address: Phone: Fax:

Physician/PA/NP Signature: Date:

Physical Exam of 7


Due Date: Incoming Fall & Summer Students – July 15th, Incoming Spring Students – December 15th

Last Name First Name M.I Date of Birth: M/D/Y Gender Banner ID#

Temp: Height: Pulse: Weight: Resp: BMI: BP: Visual Acuity Right 20/ Left 20/

Medical History Hospitalization/Surgery Allergies Medications

Does this patient, to the best of your knowledge, have a current or past history, of significant chronic or acute medical, psychological, emotional or addiction issues? Yes ___ No ___ (If yes, please attach a summary to this form)

NORMAL ABNORMAL COMMENTS Skin HEENT Neck/Thyroid/Lymph/Nodes Thorax/Lungs Cardiovascular Heart murmurs (if indicated, please enclose EKG or ECHO reports)

Abdomen Breast/GYN or Genitalia/Hernia Musculoskeletal Neurological Assessment

Is this student capable of participating in University physical education courses or tryouts for intercollegiate sports? Yes ___ No ___ Explain any exceptions: ___________________________________________________________________________

Tuberculosis History Yes No 1. Does the student have signs and symptoms of active TB disease now? 2. Has the student had signs and symptoms of active TB disease previously? If “yes” to any of the above, please complete submit documentation of all testing, (including chest x-ray reports) and treatment.

Required Tests for NCAA Athletes: Sickle Cell Solubility Test: (Attach Lab Results)

MUST BE SIGNED& STAMPED Physician/PA/NP Address: Physician/PA/NP Name: Phone: Physician/PA/NP Signature: Fax:

NOTE TO STUDENT: This form is mandatory for all undergraduate, International, ESL and EOF students. The physical examination must be completed and signed by a physician, physician assistant or nurse practitioner within the past 12 months to be valid. Students planning to participate in NCAA Athletics or the Athletic Training program must have this form completed and on file with the Student Health Services prior to scheduling their Mandatory Pre-Participation Physical Examination. Please visit the Sports Physical page of Student Health Services’ website for complete information. Date of Exam:_________________________________________

Tuberculosis (TB) Screening of 7 Due Dates: Incoming Fall & Summer Students – July 15th, Incoming Spring Students – December 15th

ALL STUDENTS must carefully review and answer ALL the following questions with your healthcare provider (this form does not require a signature):

Last Name First Name M.I Date of Birth: M / D / Y Banner ID#

Have you ever had a positive tuberculosis skin test or blood test? Yes No

Have you ever had close contact with anyone known or suspected to have active TB disease? Yes No

Were you born in one of the countries or territories listed below? If YES, circle the countries or territories. Yes No

Have you had frequent or prolonged visit to one or more of the countries or territories listed below? If YES, circle the countries or territories.

Yes No

Have you been an employee, volunteer and/or resident of high-risk congregate settings (e.g. hospital, long-term care facility, homeless shelter, correctional facility)?

Yes No

Have you been a volunteer or health care worker who served clients who are at increased risk for active TB disease?

Yes No

Have you ever been vaccinated with BCG? (A TB vaccine - not typically used in the U.S.) Yes No

Did you answer YES to any of the above questions? IF YES, you are REQUIRED to have a physician, nurse practitioner or physician assistant complete the Tuberculosis Evaluation & Testing on Page 6.

Afghanistan Algeria Angola Anguilla Argentina Armenia Azerbaijan Bangladesh Belarus Belize Benin Bhutan Bolivia (Plurinational State of) Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Central African Republic Chad China China, Hong Kong SAR China, Macao SAR Colombia Comoros

Congo Côte d'Ivoire Democratic People's Republic of

Korea Democratic Republic of the

Congo Djibouti Dominican Republic Ecuador El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji French Polynesia Gabon Gambia Georgia Ghana Greenland Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia

Iran (Islamic Republic of) Iraq Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic

Republic Latvia Lesotho Liberia Libya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States

of) Mongolia Montenegro Morocco Mozambique Myanmar

Namibia Nauru Nepal Nicaragua Niger Nigeria Northern Mariana Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Vincent and the

Grenadines Sao Tome and Principe Senegal Serbia Seychelles Sierra Leone

Singapore Solomon Islands Somalia South Africa South Sudan Sri Lanka Sudan Suriname Swaziland Tajikistan Thailand Timor-Leste Togo Trinidad and Tobago Tunisia Turkmenistan Tuvalu Uganda Ukraine United Republic of

Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian

Republic of) Viet Nam Yemen Zambia Zimbabwe

Please call Student Health Services at 856-256-4333 with any questions.



TB (Tuberculosis) Evaluation & Testing Form of 7



Last Name First Name M.I. Date of Birth: M / D / Y Banner ID#

Healthcare Provider: Make sure all questions on page 5 were answered. If you or your patient has indicated that he/she is at risk for tuberculosis. Please complete the following:

1. Did the student answer YES to any of the questions on page 5?

No _____ No more information is needed. Yes _____ Proceed to #2.

2. Has the student had a POSITIVE TB Test in the past?

No _____ Proceed to #3 Yes, the student had a Positive TB Test on: _____/_____/_____ Proceed to #4. M D Y

3. Administer TB skin test (PPD). Only acceptable if tested within last 12 months. Date place, read, and result in mm must be included. If history of BCG, consider IGRA blood test.

OR

Date Administered: ____/_____/_____ M D Y

Date Read (must be read within 48-72 hours after test was administered): _____/_____/_____ Result: ______ mm M D Y

Positive or ≥10mm _____ Proceed to #4. Chest x-ray required regardless of IGRA blood test results.

NJ Department of Education considers a reading of ≥10mm positive.

Order IGRA blood test. (T-Spot or Quantiferon) Only acceptable if tested within last 12 months.

Negative _____ Sign bottom and office stamp. MUST ATTACH LAB REPORT

Positive _____ Proceed to #4. MUST ATTACH LAB REPORT

4. Chest x-ray: REQUIRED if TB Test or IGRA is positive.

Date of chest x-ray _____/_____/_____ MUST ATTACH RADIOLOGIST’S REPORT Result: Normal _____ Abnormal _____ M D Y

5. Treatment: (TREATMENT OF TB REQUIRED FOR ACTIVE TB / TREATMENT OF LATENT TB RECOMMENDED FOR POSITIVE TB TEST)

Medication Length of Treatment

Date Started Date Completed

Not valid unless signed, stamped and dated by a Physician, PA or NP.

Print Name & Title Office Stamp

Signature

Date: Office Telephone


Consent of 7



REQUIRED for students who will be under 18 years of age when they arrive on campus. Page must be completed by the student’s parent or court-appointed legal guardian.

__________

STUDENT NAME DATE OF BIRTH

_____ _____ ________

BANNER ID # ENTRANCE DATE

__________ ________

ADDRESS

________ ________ CITY

___________ _________________ _ ___________________________

STATE, ZIP CODE PHONE

Authorization of Treatment Statement

I hereby authorize Rowan University Wellness Center staff and physicians to provide health care evaluations, treatment and other medical services as necessary. I certify, to the best of my knowledge, that the information provided in my health record is complete and accurate. In case of emergency, I authorize the Wellness Center to secure emergency medical evaluation, treatment and/or surgery at a hospital if such treatment is deemed necessary. I authorize Rowan University Wellness Center staff and physicians to share any medical information with hospital or emergency medical personnel in the case of an emergency or subsequent treatment. I understand that in the event of serious illness or injury, my parent(s) or legal guardian(s) may be notified at the discretion of the Wellness Center staff. I understand that in situations in which Wellness Center staff are concerned about suicidality, homicidality, child abuse, or court order, information can be shared with appropriate parties (e.g. emergency room staff, an identified potential victim, NJ Dept. of Children and Families, etc.) to ensure safety, wellbeing, or compliance. I understand that the Wellness Center staff, including Student Health Services nursing and medical providers, Counseling and Psychological Services counselors and psychiatry providers, and Alcohol and Other Drug Services providers have access to medical and mental health information, with the exception of psychotherapy notes, as it relates to my health care services, and I understand that any/all of these providers may disclose your health information to people outside of the Wellness Center who provide services that are part of your care. Matriculated students may be seen at the Wellness Center regardless of insurance provider. If I have purchased the student health insurance plan, I understand the plan will be billed for most services received at the Wellness Center. Medical claim information related to healthcare services received is available through the Aetna Navigator online. Chart audits may be performed to: improve healthcare operations, support medical claims, review utilization data and conduct quality assurance measures. Chart audits may be performed internally or by business associates that have entered an agreement to protect the confidentiality of your information. Please refer to our Privacy Practices for Protected Health Information for further information regarding your patient rights. A paper copy can be found in our waiting room, is available on our website, and is available for you for review when you initially check-in at the start of treatment. The Wellness Center may use your information to text/email you regarding appointment reminders and satisfaction survey requests. Certain therapies in Counseling and Psychological Services utilize email, text, videoconferencing and online support which may not be secure. These communication techniques italicized above will be described in detail should they apply to your treatment. I understand that I may decline these communication techniques in consultation with my therapist. This authorization will remain in effect as long as I am a student at Rowan University and replaces any previous authorization(s).

__________________________________________ SIGNATURE OF CLIENT OR LEGAL REPRESENTATIVE DATE

________________________________________________ __________________________________________ IF SIGNED BY LEGAL REPRESENTATIVE, RELATIONSHIP TO CLIENT DATE


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