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Medical Records & Authorizations
Below are the forms needed to authorize release of your health information. Please carefully read the purpose of each form to ensure it applies to your situation. Feel free to call our office at
1-866-874-7483 if you are unsure about which form you need to complete.
Completed forms may be sent to the fax number or mailing address below.
| Fax: |
(412) 630-8019
ATTN: Forms & Medical Records Dept. |
Mail: |
Tri Rivers Surgical Associates
ATTN: Forms & Medical Records Dept.
9104 Babcock Blvd, Suite 2120
Pittsburgh, PA 15237 |
1) Request to Release Medical Records for Personal Use
This form is intended for patients who would like to release their medical records to themselves. The records will be released directly to the patient.
Release for Personal Use
2) Request to Release Medical Records to a Third Party
This form is intended for patients who would like to release their medical records directly to a third party (i.e. insurance company, workers’ compensation carrier, physician, etc.). The records will be released directly to the party indicated on the form.
Release to a Third Party
3) Authorization to Update Primary Care Physician
This form is intended for patients who have changed their primary care physician and would like all future medical records sent to this new physician.
Update Primary Care Physician
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