Training Verification Request Form

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 is $50.

Fees will be waived for:

Current Residents/Fellows who completed training within the last 5 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**

Requestor Information

First Name Last Name Company / Institution / Board Email Address Phone Number Street Address Street Address 2 City State Zip Code

Trainee Information

Trainee First Name Trainee Last Name Other Aliases Trainee Date of Birth

Training Programs
Submit up to 3 programs. Charges will apply per program unless the additional program was an internship or transitional year.

Training Program 1 Start Date Program 1 End Date Program 1 Training Program 2 Start Date Program 2 End Date Program 2 Training Program 3 Start Date Program 3 End Date Program 3

Training Verfication and Billing

Send the verification letter to me by: (select one)

Alternative Email

Alt. Street Address Alt. Street Address 2 Alt. City Alt. State Alt. Zip Code

Waive My Fee (select reason for waiver)

Authorization and Release Form
A signed UPMC GME Authorization and Release Form (PDF) is required.
Please attach/upload your signed release form as well as any supplemental forms necessary as one document.

Document Upload

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