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Forms and Resources for UPMC for Kids Members

Member Handbook
Provides information to help you understand your UPMC for Kids benefits and how to access services.
Pharmacy Benefits Booklet
Provides a description of pharmacy services and a list of the medications that are covered.
Summary of Benefits
Provides information on UPMC for Kids benefits and copayments that apply to some members.
UPMC for Kids Exclusions
Provides information on the services and supplies that are not covered by UPMC for Kids or have limitations on the coverage.
Income Guidelines Chart
Family income guidelines used to determine eligibility for CHIP programs.
Privacy Statement
Describes how UPMC for Kids protects your child's health information.
Member Rights and Responsibilities
Lists the rights and responsibilities of UPMC for Kids members.
Member Complaints and Grievances
Provides an explanation of the procedures necessary to file a complaint or grievance with UPMC for Kids.
Notice of Privacy Practices
Describes HIPAA and the use of your child's or teen's protected health information.
Renewal Form
UPMC for Kids renewal application for CHIP health insurance in English.
Personal Representative Designation Form
Form by which the head of household gives a designated person written permission to discuss your child's health information and benefits with UPMC for Kids.
Member Authorization to Use or Disclose Protected Health Information
Form that gives UPMC for Kids written permission to share protected health information.
Quick Reference Guide
Provides information on when a prior authorization or referral is needed for a service.
Cost of Coverage
Lists copayments for some services for children enrolled in the low-cost CHIP and full-cost CHIP programs (there are no copayments for free/no-cost CHIP)
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