Fillable PDF Forms

You will need Adobe Acrobat Reader to open and fill out these forms.  
Please fax the completed forms to UMBH at 305-243-7299. 

Sample Forms

• Informed Consent
• PCP Coordination of Care

UMBH Provider

• Outpatient Initial Clinical Review
• Outpatient Continued Care Assessment
• Child & Adolescent Assessment Checklist
• Transition/Termination/Discharge Plan
• Maintenance Treatment Plan
• Family Therapy Treatment Plan
• Split Treatment Coordination Plan (for Multiple Providers)
• FARS/CFARS Summary of Scores Form 

Medicaid Forms

• Medicaid Initial Clinical Review Form (Medicaid Only)
• Medicaid Concurrent Clinical Review Form (Medicaid Only)
• FARS/CFARS Summary of Scores Form (Medicaid Only)