Forms
To minimize your wait time at the Health Center, we have provided you with some forms to print and fill out prior to your appointment.
All files are in PDF format. You'll need Adobe Reader to view these files.
Allergy Clinic
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Allergy Physician Orders (Required Form - Must be completed by a physician)
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Allergy Physician Letter (Required Form - Must be completed by a physician)
Class Excuse Self-Signed Note
Immunizations
Medical Records
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Patient Authorization to Release Protected Health Information (PHI)
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Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (General)
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Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (Behavioral Health)
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Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (SUIT)
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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.
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Patient Authorization to Release Protected Health Information (PHI)
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Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (Behavioral Health)
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UMD Behavioral Health Services Informed Consent Teletherapy/Telehealth
Faculty Staff Assistance Program
Occupational Health
Animal Handler Questionnaire
Initial Asbestos
Periodic Asbestos
Respirator Evaluation
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Notice of Privacy Practices (Please review before completing the form below. Printing is not required.)
Employment Physical
Vaccinia (Small Pox)
TDap
Hepatitis B
Paratransit
Physical Therapy
Sports Medicine
- Sports Medicine Authorization to Release Confidential Information
- Sports Medicine Mental Health History Form
Telemedicine