Common Forms For Patients

As a convenience to patients, the following links provide access to many commonly-used governmental forms. All forms are PDF files.

UPMC Forms

• 2019-2020 Parent-Guardian Release Form – Family Health Center Free Inhaler Program
• Consent for Treatment, Payment and Health Care Operations
• Personal Representative Designation
• Medical Consent Evaluation
• Authorization for Release of Protected Health Information 
• MyUPMC Pediatric Proxy Request 
• English
• Chinese
• Nepali
• Russian
• Spanish
• MyUPMC Adult Proxy Request
• English
• Chinese
• Nepali
• Russian
• Spanish

Pennsylvania Student and Child Forms

• The PIAA comprehensive physical form (required prior to participating in scholastic sports)
• Pennsylvania Driver’s License Learner’s Permit
• Pennsylvania Private Physician’s Report of Physical Examination
• Student Work Permit

Pennsylvania Department of Transportation

• Non-Commercial Learner’s Permit application
• Commercial Learner’s Permit application
• Person with Disability Parking Placard application

Pennsylvania Medical Assistance

• Health Sustaining Medication Assessment form
• Medical Assistance Employability Assessment form

Family Medical Leave Act (FMLA)

• Official website
• Employee form

Social Security Disability

• Official website
• Online application