The UPMC Personal Representative Designation form authorizes someone you choose — a spouse, adult child, friend, or caregiver — to talk with UPMC about your health information, request your records, and handle routine administrative matters on your behalf. It is a single page with three sections, requires signatures from both you and your representative, and gets mailed either to UPMC Health Plan or to the Release of Information Department for the facility where you receive care.
What the Form Does and Does Not Authorize
Once the form is on file, your representative can request access to your medical records, discuss your care with UPMC staff, and handle tasks like checking billing statements or appointment details without you being present.1U.S. Department of Health & Human Services. Guidance: Personal Representatives
The form has hard limits printed on it. It cannot be used for UPMC behavioral health patients, and it cannot be used when major healthcare decisions are involved:
- Procedures requiring informed consent, such as surgeries and invasive tests
- Admissions to or discharges from nursing homes or long-term care facilities
- Organ and tissue donation, including authorizing an autopsy
- Continuing or withdrawing life-sustaining treatment
For any of those, UPMC requires a formal power of attorney or a living will.2UPMC. Personal Representative Designation Form If you need someone making treatment decisions or managing end-of-life care, this form is the wrong tool. Use a healthcare power of attorney instead.
Filling Out the Form
The form is available as a downloadable PDF from UPMC’s website or as a paper copy at any UPMC provider’s office. Every field matters — mismatches slow processing once the form reaches records staff.
Patient Information
Enter your full legal name, date of birth, phone number, and current mailing address. Use the exact name that appears in your UPMC chart. A nickname or shortened version can cause a mismatch that delays approval.2UPMC. Personal Representative Designation Form
Representative Information
Fill in your representative’s full name, phone number, mailing address, and fax number. UPMC staff use this information to verify identity when your representative calls or visits, so the phone number needs to be one your representative actually answers.2UPMC. Personal Representative Designation Form
Signatures and Expiration Date
Both you and your representative must sign and date the form. This is the detail most people miss. Two signatures, not one. If you are physically unable to sign, a legal guardian or someone with existing legal authority over your healthcare can sign for you.2UPMC. Personal Representative Designation Form
There is an optional expiration date line. Leave it blank and the designation stays active until you stop receiving services at UPMC or revoke it in writing. Write in a date and access ends automatically then — useful when you only want help through a surgery and recovery window.
Where to Send It
Where the form goes depends on whether you are a UPMC Health Plan member or a patient at a UPMC hospital or provider office.
UPMC Health Plan members mail the completed form to:
UPMC Health Plan
PO Box 2965
Pittsburgh, PA 15230-29653UPMC Health Plan. Documents and Forms
If you receive care at a UPMC hospital or clinic and want your representative to access your medical records, send the form to the Release of Information Department. Mailing addresses vary by region. For Pittsburgh-area facilities:
UPMC, Release of Information Department
600 Grant Street, Floor 21
Pittsburgh, PA 152194UPMC. Medical Records – UPMC East
Central Pennsylvania facilities use a different address and also accept faxed forms at 717-782-3671.5UPMC. Medical Records Request – UPMC in Central Pa. If you are unsure which office handles your records, call the facility where you receive most of your care and ask for the Health Information Management department. They can confirm the correct destination and whether that location accepts faxes.
How Long It Stays in Effect and How to Revoke It
Unless you wrote in an expiration date, the designation stays active until you revoke it in writing or stop receiving UPMC services. Responsibility to cancel is entirely yours. Until you act, your prior representative keeps access across the UPMC system.
To end the authorization, send a written revocation to the same UPMC office where the original form was filed. There is no separate revocation form. A signed, dated letter stating that you are revoking the designation is enough. To replace one representative with another, submit a new designation form with the updated information and it will override the previous one.
If the Patient Is Your Minor Child
You generally do not need this form for your own child. Under federal rules, a parent, guardian, or person acting in a parental role is already treated as a minor’s personal representative and can access the child’s health information without extra paperwork.6eCFR. 45 CFR 164.502 – Uses and Disclosures of Protected Health Information: General Rules
There are exceptions. When state law allows a minor to consent to certain care alone — such as treatment for sexually transmitted infections, reproductive health services, or counseling — the parent may not automatically qualify as the personal representative for that specific care. A court order restricting a parent’s access or a confidentiality agreement between the provider and the minor can also limit what a parent can see.1U.S. Department of Health & Human Services. Guidance: Personal Representatives In Pennsylvania, minors aged 14 and older can consent to voluntary mental health treatment under state law, which can affect parental access to those records.
MyUPMC Proxy Access Is Separate
Digital access through the MyUPMC patient portal is a different process. A proxy uses their own MyUPMC account to message your doctors, view records and test results, manage appointments, and access video visits.7UPMC. MyUPMC: Secure, Convenient, Online Access to Health Information Setting up proxy access goes through the portal and may require the paper designation form to already be on file. If a caregiver needs to track lab results as they post, ask your UPMC provider’s office how to link proxy access to your representative’s MyUPMC account.