Request for Medical Expense Report

Request for Medical Expense Report

For patients wanting to receive a copy of their medical expenses via mail or email (for pick up in person or curbside at the pharmacy, please make your request at the time of pickup)
Patient Information
Full name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Phone number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Time Period

Enter a start and end date for the time period of prescription expenses being requested
From:*

MonthDayYear
To:*

MonthDayYear
Preferences
How would you like to receive your medical expense report?*

MailEmail
Please be aware that, if you would like to pick up your medical expense report in person, we ask that you cease filling out this form and instead make this request at the time of pickup (either in the store or by calling us at (651) 698-8859 when you arrive curbside). Because medical expense reports contain private health information (PHI) and patients commonly forget to pick them up, it is our policy NOT to print them out before you arrive for pickup.
Mailing address or email address where this report should be sent:*
If entering a mailing address, include apt/unit number, city, state, and zip code
Additional Requests
Is there anything else you'd like us to know about your request?
E.g., Only report non-covered items or Worker's Compensation claims
Patient Attestation
By signing this form, I understand that:
- A medical expense report can only be given or sent to the person whose information appears on such a report or to the parent or legal guardian in the case of an individual who is under the age of 18 years old.
- If I am requesting a report be mailed to an address other than the one on my or the patient in question's medical record, I must include a photocopy of my/the patient's current driver’s license or other government-issued photo ID listing said address along with this request form.
Signature of Patient (or Patient Representative)*

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Patient Representative (if signed by Patient Representative)

First NameLast Name
Relationship to Patient (if signed by Patient Representative)
Proof of identity (if applicable)

If you are requesting this report be mailed to you, please upload a photocopy of your driver's license or other government-issued photo ID here
Cancelof
Should be Empty:

Request for Medical Expense Report

Patient Information

Time Period

Preferences

Additional Requests

Patient Attestation