Download and fill out the form. Please type or print neatly and be sure to complete both Part 1 and Part 2. (Review the informational guide for completing the form)
Once you sign and date the form, make a copy for yourself and send the original to UPMC.
Mail the authorization to:
450 Melwood Avenue – Lower Level
Release of Information Department
Pittsburgh, PA 15213
Scan the form and email it to ROIRequest@upmc.edu.
After we receive your request, we will send you an invoice for the cost of the records you requested. You should receive this invoice seven to 10 days after we receive your request.
Send payment as indicated on the invoice. Records will be mailed the day after we receive payment.