Health Center Forms

• Allergy Injections - Student Instructions
• Allergy Flow Sheet (Required Form - Must be completed by a physician)
• Allergy Physician Orders   (Required Form - Must be completed by a physician)
• Allergy Physician Letter 

• Hepatitis B Vaccine Information
• Immunization Form/TB Screening Questionnaire (Required)
• Request for Medication Delivery / Infusion / Injection Administration and Teaching
• Student Involvement Immunization Form
• University Health Center Flu Vaccine Form (English)
• University Health Center Flu Vaccine Form (Spanish)

• 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)

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

Click the button below to visit Occupational Health forms page. 

Paratransit Request Form

Physical Therapy Medical History

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
• Behavioral Health 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

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

Telemedicine Informed Consent Form