Patients and Families

Forms for Parents

Requesting Your Child’s Medical Records
Medical Consent Authorization
E-mail Consent Form
Praise From Patients Form


Requesting Your Child’s Medical Records

Children’s Hospital of Pittsburgh of UPMC (CHP) has implemented an electronic health record. The Health Information Technology for Economic and Clinical Health (HITECH) Act provides individuals with a right to obtain their health information in an electronic format. CHP has the capability to release electronic records on a compact disc.

The Act provides that only a fee equal to the labor cost can be charged for an electronic request. CHP’s policy is to charge a base rate of $5 per CD and 7 cents per page.

For documentation that is released on paper for your own personal use or for a third party, such as an attorney, there will be a fee for copying and processing your request. Click here for a listing of these fees.

Children's Hospital has contracted with HealthPort, a national correspondence company, to copy and process medical records that are requested by parents and providers.

Please be advised that the staff who work in the processing department are specially trained to protect the confidentiality of your child’s records and to guard against the unauthorized release of information.

To request your child’s medical records, whether on paper or in electronic format, please complete and sign the Authorization for Release of Protected Health Information (PDF) form and send it to our Health Information Management Department as follows:

Fax: 412-692-6068

E-mail: RecordRelease@chp.edu

Mail:
Children’s Hospital of Pittsburgh of UPMC
Health Information Management Department
4401 Penn Ave.
Pittsburgh, PA 15224-1334

If you have questions, please contact us at 412-692-6834 or by e-mail at RecordRelease@chp.edu.

Authorization for Release of Protected Health Information (PDF)  (HIPAA Compliant Authorization)

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Medical Consent Authorization

Parents can complete the Medical Consent Authorization (PDF) to delegate authority to another person to make medical decisions regarding their child in the parents’ absence.

Please send your Authorization form by mail or fax to:

Children’s Hospital of Pittsburgh of UPMC
Health Information Management Department
One Children's Hospital Drive
4401 Penn Ave.
Pittsburgh, PA 15224
Fax: 412-692-6068

For questions, please call 412-692-6834.

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E-mail Consent Form

Our E-mail Consent Form allows parents to communicate with medical and support staff by e-mail, for staff who agree to communicate with families electronically. A signed consent form is required since e-mails may contain a child’s personal health information.

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Praise From Patients

“Praise from Patients” provides patients, parents and other family members with an opportunity to recognize staff members at Children’s Hospital who have created a positive patient experience. We would like to hear your stories of outstanding customer service, quality patient care and random acts of kindness. Simply fill out the recognition form and submit.

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Last Update
September 24, 2014
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Last Update
September 24, 2014
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