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Center for Health and Wellness

Center for Health and Wellness Navigation

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Forms

Medical Release & Return 

  • Authorization for Release of Protected Health Information
  • Medical Return Form
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College-Sponsored Health Insurance Forms (Gallagher/Wellfleet)

  • Prescription Override Form 
  • Medical Claim Form 

Minor Treatment/Consent 

  • Consent Form for Treatment of a Minor

Exemption Forms and Documentation

  • Vermont Colleges Vaccine Exemption Form
  • NCAA ADD/ADHD Medical Exception Documentation

Vermont State Forms for Advance Directives/Health Care Agents

  • Vermont Department of Health: Create, Register, and Edit Advance Directive or Establish Health Care Agent

Center for Health and Wellness

chw@middlebury.edu

8:15 a.m. – 5 p.m. Monday-Friday

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