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Call (413) 577-5000

Forms

Save time! Download and complete these forms:

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The following forms are available in PDF format. You’ll need Adobe’s free Acrobat Reader to view or print these documents.

Before Your First Visit

UHS Adult Assessment Form (PDF)
To be completed by all new patients.

UHS Learning and Accommodation Form (PDF)
To be completed by all new patients.

UHS Pediatric Assessment Form (PDF)
Parents: complete for your child’s first pediatrics visit.

Consent to Treat Minor Patients (PDF)
A parent/guardian must complete this form before UHS can provide medical care for those under 18.

Allergy: Immunotherapy Guidelines (PDF)
Your allergist's office must complete and return this form before the UHS Allergy Clinic can administer treatment.

Allergy: Clinic Intake Form (PDF)
To receive treatment at the UHS Allergy Clinic, you must complete this form each year.

Insurance

Insurance Information Form (PDF)
Complete this form so UHS can bill your insurance company for your care.

Health Plan Enrollment Form (PDF)
Complete this form if you want to purchase health insurance coverage for your spouse, same-sex domestic partner and/or dependent children 19 or under.

Immunizations

"Do I Need Any Vaccinations Today?" (PDF)
Review your vaccination status with this handy checklist!

Prescription transfers

Prescription transfer form
Want to pick up existing prescriptions at the UHS Pharmacy? Leaving the Amherst area and need to transfer your prescriptions to another pharmacy? Download and complete this form.

Advance Directives

Advance Directives
Advance directives are legal documents that protect your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself. The forms posted here are valid in Massachusetts, when completed by a competent adult at least 18 years old.

Release of Information

Release of Medical Information Form (PDF)
Complete this if you want UHS to release your medical information to another provider, or if you need copies of your records.

Medical Records Release to UHS (PDF)
Complete this if you want another provider to release your medical information to UHS.

E-mail Information and Consent Form (PDF)
Complete this if you want to use e-mail to communicate with your UHS provider.

For Camps, Conferences & Groups

Health History & Immunization Form (PDF)
Many camps, conferences and groups require attendees to complete a medical history form. Download a copy here.