Forms for Parents

Medical Records

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


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

Visit our Health Information Management Services to learn more about requesting medical records and fees for those requests.

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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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Wallet Medication Card

It is always important that your child’s doctor, hospital or other health care provider have a complete list of medications your child is taking. A wallet medication card is the perfect tool for ensuring you have this information at your fingertips when needed.

Simply follow these easy steps:

  • Print a Wallet Medication Card for each child.
  • Fill out the information at the top of the form.
  • Emergency Contact – Write the name and phone number of the person who should be called in case of an emergency.
  • Allergies – List all allergies and reactions your child may have including allergies to medicines, food, latex or environmental elements.
  • Other Important Information – List any additional information you think a doctor or nurse may need to know when caring for your child. For example this section might include the name of your child’s pediatrician.
  • Date This Form Last Updated – Be sure to note the date each time the form is updated.
  • Fill out the information at the bottom of the form. (All of the below information will be on the label of the medicine bottle or packaging.)
    • Start Date – Note the date your child began taking the medication.
    • Drug Name - Include all the medications that your child takes on both a regular and on an as-needed basis.
    • Strength – Note the strength of each medication.
    • Dose – Write how much of the medication your child takes each time.
    • Route – Note how the medication is administered – by mouth, injection, etc.
    • When does your child take this medicine? – Note how many times a day the medicine is taken and if it needs to be taken on an empty stomach or with food.
    • Reason – Include a brief explanation of why your child takes this medication.
    • Place the card in your wallet or keep it with your child’s insurance card.

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    Information Management

    Main Hospital, Floor 1c

    The Health Information Management (HIM) Department maintains records for all inpatient, same-day surgery and outpatient services.

    • Access to medical records is protected by Pennsylvania State Department of Health (DOH) regulations and the Health Insurance Portability and Accountability Act (HIPAA).
    • Copies of records may be released upon receipt of written authorization of the patient (if over 18 years of age) or the parent or guardian. The approved Authorization for Release of Protected Health Information is available from Children’s Web site.
    • There is a charge for copies of records unless they are requested to maintain continuity of care. For more information about obtaining copies of your child’s medical records, contact HIM at 412-692-5280 or find more information.

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