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Health Center Forms | University Health Center
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data-drupal-link-system-path="node/75">Patient Satisfaction Assessment Survey</a> </li> <li> <a href="/about-us/student-health-advisory-committee-shac" data-drupal-link-system-path="node/76">Student Health Advisory Committee (SHAC)</a> </li> <li> <a href="/about-us/student-involvement-0" data-drupal-link-system-path="node/227">Student Involvement</a> </li> </ul> </li> </ul> </nav> </div> </div> </header> <main id="main-content"> <div class="container page-content"> <div data-drupal-messages-fallback class="hidden"></div> <div class="row justify-content-center"> <div class="col-800-9"> <nav aria-label="Breadcrumb"> <ol class="breadcrumb"> <li class="breadcrumb-item"><a href="/">Home</a></li> </ol> </nav> <div data-history-node-id="77"> <div class="editor-content"> <h1>Health Center Forms</h1> <h4><strong>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.</strong></h4><p>All files are in PDF format. You'll need <a href="http://www.adobe.com/products/acrobat/readstep2.html">Adobe Reader</a> to view these files.</p><p> </p> </div> </div> <div class="section section-umd_terp_basic_page section-ut_accordion"> <div class="accordion" id="accordion-68"> <!-- test comment --> <div class="card"> <div class="card-header" id="accordion-68-header-16"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-16" aria-expanded="false" aria-controls="accordion-68-content-16"> Allergy Clinic </button> </div> <div id="accordion-68-content-16" class="collapse" aria-labelledby="accordion-68-header-16" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--54"> <ul><li><a href="https://health.umd.edu/sites/default/files/2024-06/Allergy%20Student%20Instructions%2001-21.pdf">Allergy Student Instructions</a></li><li><a href="https://health.umd.edu/sites/default/files/2025-02/Allergy%20Immunotherapy%20Chart%203%20vials%20updated%20Feb%202025%20%281%29%20use%20this.pdf">Allergy Flow Sheet</a> <em>(Required Form - Must be completed by a physician)</em></li><li><a href="https://health.umd.edu/sites/default/files/2025-02/Allergy%20Physician%20Orders%20Feb%202025%20updated%20use%20this.pdf">Allergy Physician Orders </a> <em>(Required Form - Must be completed by a physician)</em></li><li><a href="https://health.umd.edu/sites/default/files/2024-07/Allergy%20Letter%20to%20MD%2001-21.pdf">Allergy Physician Letter</a> </li></ul> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-17"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-17" aria-expanded="false" aria-controls="accordion-68-content-17"> Class Excuse Self-Signed Note </button> </div> <div id="accordion-68-content-17" class="collapse" aria-labelledby="accordion-68-header-17" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--56"> <p><a href="https://health.umd.edu/sites/default/files/2024-07/Medical_Attestation%202-2023.pdf">The template can be found here.</a></p> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-18"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-18" aria-expanded="false" aria-controls="accordion-68-content-18"> Immunizations </button> </div> <div id="accordion-68-content-18" class="collapse" aria-labelledby="accordion-68-header-18" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--58"> <ul><li><a href="https://health.umd.edu/sites/default/files/2024-07/Hepatitis%20A%20Printable.pdf">Hepatitis B Vaccine Information</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-06/Immunization%20Form%205-2024_0.pdf">Immunization Form/TB Screening Questionnaire <em>(Required)</em></a></li><li><a href="https://health.umd.edu/sites/default/files/2024-06/OccHealth-StudentInvolvement-Immunization%20Form.pdf">Student Involvement Immunization Form</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-06/2024-2025%20Flu%20Vaccine%20Questionnaire%20%28English%29.pdf">University Health Center Flu Vaccine Form (English)</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-06/2024-2025%20Flu%20Vaccine%20Questionaire%20%28Spanish%29.pdf">University Health Center Flu Vaccine Form (Spanish)</a></li></ul> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-19"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-19" aria-expanded="false" aria-controls="accordion-68-content-19"> Medical Records </button> </div> <div id="accordion-68-content-19" class="collapse" aria-labelledby="accordion-68-header-19" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--60"> <ul><li><a href="https://drupal10-health-umd.pantheonsite.io/sites/default/files/2024-06/PHI%20Form%2011-2023.pdf">Notice of Privacy Practices</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-08/PHI%20Form%208-2024.pdf">Patient Authorization to Release Protected Health Information (PHI)</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-07/PPE%20FORM%202015.pdf">Pre-Participation Physical Form</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-07/Consent_Financial_Privacy3-2019-GENERAL-jmk%20%281%29.pdf">Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (General)</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-07/Consent_Financial_Privacy3-2019-Behavioral-Mental%20Health-jmk%20%281%29.pdf">Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (Behavioral Health)</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-07/Consent_Financial_Privacy3-2019-SUIT-jmk_0%20%281%29%20%281%29.pdf">Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (SUIT)</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-07/Consent_Financial_Privacy3-2019-CARE-jmk-3.pdf">Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (CARE)</a></li></ul> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-20"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-20" aria-expanded="false" aria-controls="accordion-68-content-20"> Behavioral Health </button> </div> <div id="accordion-68-content-20" class="collapse" aria-labelledby="accordion-68-header-20" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--62"> <p><em>Prior to your first appointment at the Mental Health Service, go to </em><a href="https://myuhc.umd.edu/"><em><strong>myuhc.umd.edu</strong></em></a><em> 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.</em></p><ul><li><a href="https://health.umd.edu/sites/default/files/2024-07/triage%20form%20UHC%20Behavioral%20Health%2010-19.pdf">Behavioral Health Triage Form</a></li><li><a href="https://health.umd.edu/node/83">Notice of Privacy Practices</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-09/PHI%20Form%209-2024%20%28BH%29.pdf">Behavioral Health Patient Authorization to Release Protected Health Information (PHI) </a></li><li><a href="https://health.umd.edu/sites/default/files/2024-07/Consent_Financial_Privacy3-2019-Behavioral-Mental%20Health-jmk%20%281%29.pdf">Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (Behavioral Health)</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-06/UMD%20BHS%20Informed%20Consent.final%20version%203-31-2020.pdf">UMD Behavioral Health Services Informed Consent Teletherapy/Telehealth</a></li></ul> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-21"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-21" aria-expanded="false" aria-controls="accordion-68-content-21"> Faculty Staff Assistance Program </button> </div> <div id="accordion-68-content-21" class="collapse" aria-labelledby="accordion-68-header-21" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--64"> <ul><li><a href="https://health.umd.edu/sites/default/files/inline-files/Consent_Financial_Privacy3-2019-FSAP-jmk.pdf">Patient Consent, Assignment of Benefits, and Financial Responsibility Agreement (FSAP)</a></li><li><a href="https://health.umd.edu/sites/default/files/inline-files/FSAP%20Statement%20of%20understanding.pdf">FSAP Statement of Understanding</a></li></ul> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-22"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-22" aria-expanded="false" aria-controls="accordion-68-content-22"> Occupational Health </button> </div> <div id="accordion-68-content-22" class="collapse" aria-labelledby="accordion-68-header-22" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--66"> <p><strong>Click the button below to visit Occupational Health forms page. </strong></p><p> </p> </div> </div> <a href="/umd-employees/occupational-health/occupational-health-forms" class="btn btn-primary" target="_self"> Occupational Health Forms </a> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-23"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-23" aria-expanded="false" aria-controls="accordion-68-content-23"> Paratransit </button> </div> <div id="accordion-68-content-23" class="collapse" aria-labelledby="accordion-68-header-23" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--69"> <p><a href="https://health.umd.edu/sites/default/files/2024-08/Paratransit%20Request%20Form.pdf">Paratransit Request Form</a></p> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-24"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-24" aria-expanded="false" aria-controls="accordion-68-content-24"> Physical Therapy </button> </div> <div id="accordion-68-content-24" class="collapse" aria-labelledby="accordion-68-header-24" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--71"> <p><a href="https://health.umd.edu/sites/default/files/2024-08/pt_med_hx.pdf">Physical Therapy Medical History</a></p> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-25"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-25" aria-expanded="false" aria-controls="accordion-68-content-25"> Sports Medicine </button> </div> <div id="accordion-68-content-25" class="collapse" aria-labelledby="accordion-68-header-25" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--73"> <ul><li><a href="https://health.umd.edu/sites/default/files/2024-08/Sports%20Medicine%20Authorization%20for%20Release%20of%20Confidential%20Information.pdf">Sports Medicine Authorization to Release Confidential Information</a></li><li><a href="https://health.umd.edu/sites/default/files/2024-08/Sport%20Psych%20PPE%20Form_0.pdf">Sports Medicine Mental Health History Form</a></li></ul> </div> </div> </div> </div> </div> <div class="card"> <div class="card-header" id="accordion-68-header-26"> <button class="btn" data-toggle="collapse" data-target="#accordion-68-content-26" aria-expanded="false" aria-controls="accordion-68-content-26"> Telemedicine </button> </div> <div id="accordion-68-content-26" class="collapse" aria-labelledby="accordion-68-header-26" data-parent="#accordion-68" > <div class="card-body"> <div> <div class="editor-content" id="umd_terp_paragraph--75"> <p><a href="https://health.umd.edu/sites/default/files/2024-08/Telemedicine%20Informed%20Consent%20-%20Health%20Ctr%202020.05.07_DSA%20LOGO.pdf">Telemedicine Informed Consent Form</a></p> </div> </div> </div> </div> </div> </div> </div> <div id="chat"> <iframe style="border:0;bottom:85px;height:0;position:fixed;right:10px;width:0;z-index:999;" id="chatbox" src=""></iframe> <button class="expand-button" aria-label="Maximize Chatbot" id="expandButton" 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