VA Pittsburgh Healthcare System

PIRATE Applicants must complete and submit BOTH the PIRATE Application form and the PIRATE Medical Information Form below.

PIRATE Application Form
Apply to become a PIRATE participant.
(NOTE: application form must be completed by applicant or family member/friend)

PIRATE Medical Information Form
Concerning the general health of the applying Veteran.
(NOTE: application form must be completed by applicant or family member/friend)

Please print out and fill in the application and medical information form,
then mail or FAX both forms to:

VA Pittsburgh Healthcare System
PIRATE
University Drive 132 SP-U
Pittsburgh, PA 15240

Fax: 412-360-6426

Consultation Request Form
(NOTE: consultation form must be completed by the applicant's primary care provider)

VISN 4 Map