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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:
*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.
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.