Please fill out this form and click "Submit". Once the submission has been reviewed, an invoice with payment instructions (3-5 business days) will be sent to your email address unless an applicable fee waiver is selected.
Fee per training program request:
- Training end date between January 1, 2012, and December 31, 2022: $25
- Training end date between January 1, 2000, and December 31, 2011: $50
- Training end date between January 1, 1990, and December 31, 1999: $75
- Training End date between January 1, 1960, and December 1, 1989: $100
Fees will be waived for:
- Current Residents/Fellows who completed training within the last 3 years (starting from the year program was completed)
- U.S. Department of Veteran Affairs and military members (proof of current status is required or use VA/Military email when submitting)
- UPMC Hospitals/ UPMC Programs
Post Graduate Forms/State Board Forms:
- Completion of any Post Graduate/State Board Form must require the placement of the Hospital Seal. If the form does not require the placement of the Hospital Seal, it will be replaced by the UPMC Verification Form
- Post Graduate/State Board Form must be uploaded with the release form as ONE attachment during the submission process
- No charge for Post Graduate/State Board Forms
Please allow 10-15 business days from the time we receive payment for the completion of requests. Additional time may be required for dates prior to 1990 and for Post Graduate/State Board Forms that require the Program Director Signature.
- Signed Release Form/Consent Form must have a signature (electronic accepted) within a 12 month time period of submission
- CAHQ is not accepted/supported by UPMC
- Refunds will be given based on review and decision by the UPMC Medical Education Office if the program name and/or dates of training history cannot be verified.
- If submitting requests for multiple trainees then a separate form will need to be submitted for each.
- UPMC GME Authorization and Release Form (PDF)
**Dental and Pharmacy requests should not be submitted via this form but should instead be submitted directly to the program**