In order to provide you with the best care and to comply with certain legal requirements, Pittsburgh Mercy will create a record of your care and service. Your privacy is very important to us. The Health Insurance Portability and Accountability Act and the Health Information Technology for Economic and Clinical Health Act, found in Title XII of the American Recovery and Reinvestment Act of 2009, collectively referred to as “HIPAA” laws, establish standards to assure that the personal and health information that identifies you is kept private. Our Notice of Privacy Practices outlines both your rights and our legal duties to protect your privacy. We invite you to read our Notice of Privacy Practices.
Authorization for Use & Disclosure of Protected Health Information
Please print, complete, and return our Authorization for Use & Disclosure of Protected Health Information Form. This form allows us to communicate about your care with your other health care providers. Forms may be returned via U.S. mail to the attention of: Health Information Management Department, Pittsburgh Mercy, 1200 Reedsdale Street, Pittsburgh, PA 15233, or via fax at 412-320-3278. If you have questions about this form, please call our Health Information Management Department at 412-320-2380.
download the authorization for use & disclosure of protected health information form
Informed Consent for Telehealth Services
Please print, complete, and return our Informed Consent for Telehealth Services to your care provider at your first appointment. This form allows us to communicate with you via HIPAA-compliant, interactive videoconferencing services. If you have questions about this form, please contact your provider.
DOWNLOAD THE INFORMED CONSENT FOR TELEHEALTH SERVICES FORM
Navigating the world of benefits can be confusing. We can answer your questions and help you apply for the following types of benefits:
Social Security Income/Social Security Disability Income (SSI/SSDI) Outreach, Access and Recovery – also known as SOAR – assists eligible individuals in applying for SSI and SSDI benefits that are administered by the Social Security Administration. SOAR is intended for adults, age 18 years or more, who reside in Allegheny County, and meet other eligibility and income requirements.
- Pennsylvania Medicaid
Paying For Services
If you have health insurance coverage:
- You are responsible for providing the insurance information required for billing.
- We will bill your insurance carrier the full cost of covered services.
- You are responsible for paying the co-insurance, co-pay, and/or deductible amounts for covered services.
If you don’t have health insurance coverage:
- Charges for services that you receive may be reduced by an additional fee that’s determined by proof of your income.
For more information, visit our insurances & billing page.
Help Us To Help You
We’re here to serve you. Here are a few ways you can help us to help you and make the most of your experience with us. Please:
- Keep your scheduled appointments with your service providers.
- If you’re unable to keep a scheduled appointment, please remember to call us to let us know. We’ll work with you to reschedule.
- When coming for a first-time appointment, please arrive 10-15 minutes early to complete the necessary forms.
- Arrive on time to your other scheduled appointments.
- Let your service provider know if there is a change in your:
- Phone number
- Family size.
- Read the bulletin boards in the waiting area to find helpful resources, information, and ways to connect with others in the community. If you need assistance, please ask a member of your care team.
- Can’t find what you’re looking for? Please ask a member of your care team
Page Updated: March 31, 2022