Training Verification Request Form

Please fill out this form and click "Submit". Once we receive this form and a signed Authorization and Release form, we will review your request. Once reviewed, an invoice with payment instructions will be sent to your email address unless an applicable fee waiver is selected.

Fee per training program request:

• Training end date after December 31, 2009: $25
• Training end date between January 1, 2000 and December 31, 2009: $50
• Training end date between January 1, 1990 and December 31, 1999: $75
• Training End date between January 1, 1960 and December 1, 1989: $100
• Additional charges may apply for forms that require notarization or Director signature

*Fees will be waived for current residents, those who have completed training within the last 3 years, U.S. Department of Veteran Affairs and military members and for UPMC hospitals / programs submitting the request.

**Dental and Pharmacy requests should not be submitted via this form but should instead be submitted directly to the program

Once payment is received the request will be filled and sent to the email address provided.

Please allow 10-15 business days from the time we receive payment for completion of requests. Additional time may be required for dates prior to 1990 and for forms that require Director Signatures.

• Signed Release Form/Consent Form must have a signature (electronic accepted) within a 12 month time period of submission
• CAHQ are not accepted/supported by UPMC

Refunds will be given based on review and decision by the UPMC Medical Education Office if the program name and/or dates of training history cannot be verified.

If submitting requests for multiple trainees then a separate form will need submitted for each.