Important Notice: Pennsylvania Life and Health Insurance Company Guarantee (PDF)
HIPAA Privacy Forms
*All documents are in PDF format
UPMC Health Plan (Commercial)
- Notice of Privacy Practices
- Personal Representative Designation Form
- Member Authorization to Use/Disclose PHI
- Alternate Address Request Form
- Formulario de nombramiento de representante personal
UPMC for Life (Medicare)
- Notice of Privacy Practices HMO/PPO Members
- Personal Representative Designation Form
- Member Authorization to Use/Disclose PHI
UPMC for You (Medical Assistance)
- Notice of Privacy Practices
- Notificación de prácticas de privacidad
- Personal Representative Designation Form
- Formulario de Designación de Representante Personal
- Member Authorization to Use/Disclose PHI
- Personal Representative Designation Form – 繁體中文/Mandarin (Chinese)
- Personal Representative Designation Form – 한국어/Korean
- Personal Representative Designation Form – ខ្ខ្មែរ/Mon-Khmer (Cambodian)
- Personal Representative Designation Form – Tiếng Việt/Vietnamese
- Personal Representative Designation Form – Русский/Russian
- Personal Representative Designation Form – नेपाली/Nepali
- Personal Representative Designation Form –
نموذج تعيين الممثل الشخصي
UPMC for Kids (Children's Health Insurance Program)
- Notice of Privacy Practices
- Personal Representative Designation Form
- Formulario de nombramiento de representante personal
- Member Authorization to Use/Disclose PHI
- Autorización del miembro para usar o divulgar información de salud protegida
- Notificación de prácticas de privacidad
UPMC Medicare Special Needs Plans
- Notice of Privacy Practices
- Personal Representative Designation Form
- Formulario de Designación de Representante Personal
- Member Authorization to Use/Disclose PHI
UPMC Community HealthChoices
- Notice of Privacy Practices
- Personal Representative Designation Form
- Formulario de Designación de Representante Personal
- Personal Representative Designation Form - 繁體中文/Mandarin (Chinese)
- Personal Representative Designation Form - 한국어/Korean
- Personal Representative Designation Form - ខ្ខ្មែរ/Mon-Khmer (Cambodian)
- Personal Representative Designation Form - Tiếng Việt/Vietnamese
- Personal Representative Designation Form - Русский/Russian
- Personal Representative Designation Form - नेपाली/Nepali
- 2024 Personal Representative Designation Form –
نموذج تعيين الممثل الشخصي - Member Authorization to Use/Disclose PHI