In order for our office staff to complete any medical or insurance form or letter request, we need to inform you of our office procedures for handling such paperwork. Our Neurology Department requires that you complete an Authorization for Release of Protected Health Information form (below) so that we can legally share information regarding your medical condition with the person/ company requesting such information.
A fee will be charged by our office to complete your request. A fee schedule is also enclosed (with release). We charge fees for forms or letters as this work is uncompensated and creates additional work for our staff especially when requested outside of your scheduled appointment.
We will complete your request upon receipt of payment and completion of all forms. (See form fee and release forms and instructions). Once the forms are completed, we mail the form or letter to the requesting individual or company unless you state otherwise. A copy will be mailed to you for your records.
If you require this form to be completed sooner that 4 weeks, please schedule an appointment with our physician assistant Ryan Orie PA-C by calling 412-692-4920 and press number 1.
Utility Shut off notice:
Please let us know via phone call or MY UPMC that you are having a Utility Shut off Notice form faxed to us. Form should be faxed to 412-692-4907. If your utility provider does not use a form and requires that a physician call to delay turning off service please use MY UPMC or call us with the following information: Name, address, name, name the bill is under and account number. We will attempt to call the utility provider within 72 hours of receiving this information.
Please mail or fax your form to us at 412-692-4907. We will attempt to complete and return within 72 hours.
We have forms from the Pennsylvania Department of Transportation that we can complete for you. If you reside outside of the state of PA, please mail the form to us and we will be happy to complete the form should your condition limit your ability to walk. You may request this during an appointment, or in between visits.
Release of Records UPMC is committed to protecting the privacy of your medical information. To safeguard your privacy, you must complete and sign a form before records can be sent. We use an outside vendor who handles our releases. Should you want to request records, our form is available below for you to download. Once we receive an accurately completed Release of Record form we forward it to Healthport. On the form, you must indicate what records are to be released and where they are to be sent. To check the status of your record release you may call 412-648-6057. You may return the release form by mail or fax at 412-692-4907. We are only able to release our records to you (example your progress notes and tests ordered by our physicians on staff in our own department.) We cannot release records we received about you from another provider. Please note there may be a cost involved for you to receive records.
If you are requesting records related to a hospitalization at a UPMC hospital, you will need to request this by phone 412-802-0100 or fax: 412-683-1492.
How to Complete this Form
We will not honor this form unless all required fields are completed. We cannot honor blanket requests for "any and all records" or the "entire file." You must specify the information you are requesting. Please write your full name (first middle initial and last name(no nicknames)), date of birth (month, day and year),last 4 digits of your social security number, name of facility or person who is to receive records, phone, fax and full address as records are mailed. In Part 1 please designate specific dates or the year that records would be released. If you want all previous records as you are transferring care, you would place year of your first appointment on that line. If you only need records release for the last year you would place that year next to date if you are unsure of specific dates or visits or tests. Please determine what records are needed and check all boxes related to records you need example progress notes, radiology reports, laboratory reports.
To Authorize Others to View and Manage Your Medical Records