How to Fill Out and Submit the UPMC Medical Records Release Form

The UPMC Medical Records Release Form is a one-page authorization that tells any UPMC facility to send your records to a person, provider, or organization you name. You complete two parts: your identifying information and the recipient’s details, then the specific visits and document types you want sent. Sign and date it, attach any representative paperwork if you’re not the patient, and submit it to the Health Information Management department of the UPMC hospital that holds the records, through the Verisma portal for physician-office records, or through the UPMC Patient Portal. The authorization is valid for 90 days from the date you sign unless you write in a different expiration, and no authorization can run longer than one year.¹

Part 1: You, the Recipient, and the Purpose

At the top of the form, fill in your full legal name, date of birth, and the last four digits of your Social Security number. Below that, enter the name, phone number, fax number, and complete mailing address of whoever should receive the records.

Check one box for the purpose: continuing care or facility transfer, legal proceedings, personal use, insurance, or “other” with a write-in line. If you’re requesting your own records, the purpose field is technically optional. The form notes “Purpose is not required for patient access.”¹

Next, pick the disclosure format (paper, CD, fax, or other) and how you want delivery (U.S. mail, in-person pickup, fax, email, or direct address). Fax is restricted to provider-to-provider transfers.

Part 2: Which Records You Want

Check the type of visit: inpatient, emergency department, physician office or clinic, same-day surgery, outpatient, or other. Write in the specific dates of service. A narrower date range keeps the request faster to process and cheaper to fulfill, because the facility isn’t pulling your entire chart.

Then check the boxes for the documents you need. The form lists more than two dozen options, grouped roughly as:

Abstract, a summary bundle containing the history and physical, consult notes, test results, and discharge summary
Lab and diagnostic reports, including laboratory results, radiology, EKG, cardiology studies, pathology, and pulmonary function tests
Clinical notes, including physician progress notes, nursing notes, operative reports, and rehabilitation records
Medication administration records and physician orders
Discharge summary and discharge instructions

If you only need a few lab results from one visit, check just those boxes rather than requesting everything. Targeted requests move faster and generate smaller invoices.¹

At the bottom, check the UPMC hospital where you were treated. If your care spanned multiple UPMC hospitals, you may need to submit a separate form for each one, because each hospital’s Health Information Management department handles its own records.²

Signing the Form

The form has two signature lines, one for the patient and one for an authorized representative. The patient must be at least 14 years old to sign for themselves. If the patient cannot physically sign, the form allows an oral authorization witnessed by two people, each of whom also signs and dates the form.¹

Sensitive Records That Need Extra Steps

Three categories of information get special handling because state and federal law impose stricter confidentiality rules.

HIV and AIDS records cannot be released through the standard authorization. Pennsylvania’s Confidentiality of HIV-Related Information Act requires a separate “Authorization for Disclosure of HIV-Related Information.” If your request covers both HIV-related and other records, you need both forms.³ The HIV form must identify the specific person or organization making the disclosure, the recipient, the purpose, and an expiration date. General language authorizing “release of all medical records” does not satisfy the statute.⁴

Mental health records and drug or alcohol treatment records from a licensed facility have their own checkboxes on the UPMC form. You have to specifically check or initial those boxes. If you leave them blank, the facility will withhold that information even if you checked “all records” elsewhere.¹

Signing on Someone Else’s Behalf

If you’re not the patient, UPMC requires proof of your legal authority. The form lists four representative categories, each with its own attachment:

Parent or legal guardian. Attach a copy of the guardianship order. A biological parent requesting a minor child’s records can instead attach a birth certificate or other documentation of legal parentage.³
Power of attorney. Attach the POA document, which must specifically grant access to medical information.
Next of kin of a deceased patient. Attach a copy of the death certificate.
Executor or administrator of an estate. Attach the letters testamentary or letters of administration issued by the court.¹

For deceased or incapacitated patients, the Pennsylvania Department of Health accepts a power of attorney, estate administrator papers, or other legal documentation showing authority to act for that person.³

Where to Submit the Completed Form

How you submit depends on where you were treated.

UPMC Hospitals

Every UPMC hospital runs its own Health Information Management department. After completing the form and checking the correct facility, mail the signed authorization to the address listed on that hospital’s medical records page. For some southwest Pennsylvania locations, the centralized mailing address is:

UPMC, Release of Information Department
600 Grant Street, Floor 21
Pittsburgh, PA 15219⁵

UPMC runs hospitals across southwest, northwest, central, north central, and west central Pennsylvania, plus one in Maryland, and submission addresses vary by region. Check the specific hospital’s medical records page on upmc.com before you mail anything.²

UPMC Physician and Provider Offices

Records from a UPMC doctor’s office go through Verisma, an online records-retrieval platform. Instead of mailing the paper form, you submit directly through the Verisma portal linked from UPMC’s medical records page. This online option is not available for patients in UPMC Central Pennsylvania (Harrisburg, Carlisle, Hanover, Lititz, and York); those patients should contact the provider’s office directly.²

UPMC Patient Portal

If you have a Patient Portal account, you can request records without mailing anything. Go to the Sharing Hub, choose to share your health information with yourself, and pick a download or a formal copy. Completed requests appear in the Document Center under “My Record.”⁶ The portal skips postal transit entirely, so it tends to be the quickest route for records you want for yourself.

Fees

Pennsylvania sets maximum fees providers can charge, and the figures reset every January. The 2026 rates, effective January 1, 2026:

Pages 1–20: up to $2.00 per page
Pages 21–60: up to $1.48 per page
Pages 61 and beyond: up to $0.52 per page
Search and retrieval fee: up to $29.61

Providers may also pass along actual postage and shipping.⁷

Two flat fees apply in specific situations. Records requested to support a Social Security claim or a federal or state needs-based program cost $37.52. Records requested by a district attorney cost $29.61. When a flat fee applies, the provider cannot add the search and retrieval charge on top.⁷

When you request your own records, the search and retrieval fee does not apply. That $29.61 is only allowed when someone other than the patient or the patient’s personal representative is requesting. Federal HIPAA rules govern patient-access fees and prohibit charging for search and retrieval time on electronic copies.⁷ UPMC also doesn’t charge when it releases records directly to another physician or healthcare facility.²

How Long It Takes

Under HIPAA, UPMC must act on your access request within 30 days of receiving it, either providing the records or sending a written denial that explains why. If the facility can’t meet 30 days, it can take a single 30-day extension, but only if it sends you a written explanation and a completion date before the original deadline expires.⁸

Targeted requests, like a discharge summary from a single visit, often arrive in under two weeks. Broader requests across years and departments take longer. If you haven’t heard anything after three weeks, call the Health Information Management department at the facility you submitted to.

Canceling the Authorization Later

You can revoke a signed authorization at any time by sending a written cancellation to the facility listed on the front of the form. Revocation stops future disclosures only; it does not pull back records already released before the facility received your cancellation.⁹

One caution: revoking an authorization that an insurance company is using can disrupt claims processing. If the insurer can’t access the records it needs to evaluate your claim, the financial responsibility may shift back to you. If you want to narrow access rather than cancel it, submit a new authorization with a tighter date range or a shorter list of record types, and revoke the old one at the same time.

1
UPMC. UPMC Medical Records Release Form
2
UPMC. Requests for Medical Records
3
Commonwealth of Pennsylvania. Medical Records Requests
4
Pennsylvania General Assembly. Confidentiality of HIV-Related Information Act
5
UPMC. Medical Records – UPMC East
6
UPMC. Portal Updates in Central and Northwest Pa. or Nearby Areas
7
Commonwealth of Pennsylvania. Medical Record Fees
8
eCFR. 45 CFR 164.524 – Access of Individuals to Protected Health Information
9
UPMC. Authorization for Release of Protected Health Information