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Required Forms

Required Immunizations Form
  • All new UMass students: Have your healthcare provider complete and sign this form, then log in to the UMass Patient Portal and go to Action Items > Immunizations (syringe icon) to submit your records.
  • Alternatively, you may obtain and submit official immunization records from your provider, school, or military sources in lieu of the signed Required Immunizations Form.
  • Complete immunization records are due by the add/drop deadline of your first semester at UMass.
Health Intake Form (Adult Health & Learning Accommodation Assessment)
  • To be completed by all new patients.
  • Either download and print this form, or log into the UMass Patient Portal and go to Action Items > Forms (pencil icon); select and complete the Health Intake Form.
Consent to Treat Minor Patients
  • Will you be under age 18 when you start at UMass? If so, this form must be signed by your parent/guardian before you can receive medical care at UHS.
  • After obtaining your parent/guardian's signature, login to the UMass Patient Portal and go to Action Items > Uploads to upload all your required forms.
Acknowledgment of Receipt of the Notice of Privacy Practices
  • To be completed by all new patients.
  • 18 or older? Complete this form on the UMass Patient Portal under Action Items > Forms (pencil icon).
Patient Financial Responsibility
  • To be completed by all new patients.
  • 18 or older? Complete this form on the UMass Patient Portal under Action Items > Forms (pencil icon).

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 linked here are valid in Massachusetts, when completed by a competent adult at least 18 years old.
  • Bring or mail completed forms to University Health Services c/o Medical Records, 150 Infirmary Way, Amherst, MA 01003-9288.

Allergy Injection Services

Immunotherapy Guidelines (Allergy Injection Services)
  • Your allergist's office must complete and return this form before UHS Allergy Injection Services can administer treatment.
Intake Form (Allergy Injection Services)
  • To receive treatment from UHS Allergy Injection Services, you must complete this form each year.

Insurance Forms

Insurance Information Form
  • Provide your insurance information so UHS can bill your insurance company for your care.
  • Instead of downloading this form, patients with portal access can log into the UMass Patient Portal and enter insurance information under Action Items > Insurance (umbrella icon).
Health Plan Enrollment Form
  • Complete this form if you want to purchase health insurance coverage for your spouse, same-sex domestic partner and/or dependent children under age 26.

Medical Records/Release of Information

Release of Information
  • Complete this if you want UHS to release your medical information to another provider, or if you need copies of your records.
  • Current Patients: Complete this form on the UMass Patient Portal under Action Items > Forms (pencil icon).
Authorization to Obtain
  • Complete this form if you would like to have another provider release your records to UHS.

Pediatrics

Pediatric Assessment Form
  • Parents/guardians, complete this form for your child’s first pediatric visit.

Programs & Camps

Programs & Camps

​​​​​​Many camps, conferences and groups require attendees to complete a medical history form. Download a copy here.

Hampshire College Required Immunization Form

For Hampshire College students.