Allergy Clinic

• Allergy Student Instructions

• Allergy Flow Sheet

• Allergy Physician Orders (Required Form - Must be completed by a physician)

• Allergy Physician Letter   (Required Form - Must be completed by a physician)

Class Excuse Self-Signed Note

• The template can be found here.

 Immunizations

• Hepatitis B Vaccine Information

• Immunization Form/TB Screening Questionnaire (Required)

• Instructions for providing Immunization Records

• Student Involvement Immunization Form

• University Health Center Flu Vaccine Form (English)

• University Health Center Flu Vaccine Form (Spanish)

• Request for Medical Exception from COVID-19 Vaccination

Medical Records

• Notice of Privacy Practices

• Patient Authorization to Release Protected Health Information (PHI)

• Pre-Participation Physical Form

• Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (General)

• Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (Behavioral Health)

• Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (SUIT)

• Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (CARE)

Behavioral Health

Prior to your first appointment at the Mental Health Service, go to myuhc.umd.edu and complete the questionnaires for your appointment (you must have an appointment scheduled in order to be able to complete the paperwork).  Don't forget to click "SUBMIT" when you are finished.  Please do not print the questionnaire and bring it to your appointment.  If you are unable to complete this paperwork prior to your appointment, you can arrive 20 minutes early to your appointment to complete the questionnaire on one of our computers.

• Behavioral Health Triage Form

• Notice of Privacy Practices

• Patient Authorization to Release Protected Health Information (PHI) 

• Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (Behavioral Health)

• UMD Behavioral Health Services Informed Consent Teletherapy/Telehealth

Faculty Staff Assistance Program

• Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (FSAP)

• FSAP Statement of Understanding

Occupational Health

Animal Handler Questionnaire

• Notice of Privacy Practices 

• Animal Handler Assessment Form

Initial Asbestos

• Initial Asbestos

Periodic Asbestos

• Periodic Asbestos

Respirator Evaluation

• Notice of Privacy Practices (Please review before completing the form below. Printing is not required.)

• Instructions for completing your Respirator Questionnaire

Employment Physical

• Occupational Health (OH) History

• DOT Medical Examination Report Form

• Student Involvement Immunization Form

Vaccinia (Small Pox)

• OHC Smallpox Medical History and Consent Form

• Important Information About Vaccinia (Smallpox) Vaccine

• Vaccinia (Smallpox) Vaccine Request Form and Use Agreement

TDap

• Tdap Vaccine Information & Waiver

Hepatitis B

• Hepatitis B Vaccine Form

Paratransit

• Paratransit Request Form

Physical Therapy

• Physical Therapy Medical History

Sports Medicine

• Sports Medicine Authorization to Release Confidential Information
• Sports Medicine Mental Health History Form

Telemedicine 

• Telemedicine Informed Consent Form