BRAIN ONLY AUTOPSY PERMISSION FORM
You have been referred to this site because you have made arrangements for a BRAIN-ONLY autopsy at the University of Pittsburgh Medical Center. These arrangements may have been made through the Alzheimer Disease Center (ADRC), the ALS Disease Center or through a UPMC physician. If you have not made such arrangements please call the UPMC Division of Neuropathology (412) 647-9417 during standard working hours. In emergent situations, the neuropathologist on-call can be reached by calling (412) 647-2345 and asking for the neuropathologist on-call. BRAIN-ONLY autopsies can be performed without such prior arrangements but you may be billed for professional and technical fees up to $2000.
Formal legal permission must be obtained prior to performing the brain autopsy. Click here to print out the PDF file of the UPMC BRAIN-ONLY autopsy permission form and fill in the requested information and complete section 1 as illustrated in the attached example. Most brain autopsies are performed to promote research into brain diseases. If this is your choice please check the boxes in both parts 2 and 3. If you choose not to relinquish the rights discussed in part 3, it places legal encumbrances on any specimens obtained that greatly discourages their use in any research project.
If permission is being given through a verbal telephone communication use the part 4 instead of part 1.
Most funeral homes in western Pennsylvania have experience in coordinating the transportation to UPMC Presbyterian hospital. The BRAIN-ONLY autopsy permission form and copies of available medical history should be transported with the deceased. Transport costs are typically part of the family's funeral expenses unless prior arrangements have been made by a specific research program.
Click HERE to view a sample of a completed Brain Only Autopsy Permission form.