UPMC Northwest

UPMC Northwest

To request your records,

• Download this form.
• Fill out the form. Please type or print neatly. Be sure to complete both Part 1 and Part 2. 
• Sign and date the form.
• Make a copy for yourself.
• Send the original to:
  

  UPMC Northwest
  Health Information Management Department
  100 Fairfield Drive
  Seneca, PA 16346