Request for Access to Records

Request for Access to Records
Patient Name*

First NameLast Name
Date of Birth*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Please mark the records you are requesting access to:*

Patient File (Demographic Information)Insurance DataPrescription Profile with pricePrescription HardcopyPayment InformationVaccine HistoryOther
I am requesting a copy of my records for the following time frame:
From:From To: To*
If access to records is granted, I would like my requested records:*

Mailed to the address listed aboveEmailed to the email address listed aboveAvailable for pickup at the pharmacy
I understand that if the pharmacy grants access to records, the pharmacy will provide the requested records within thirty days from receipts of request. Also, I understand there may be a cost based fee charges to proccess this request and the pharmacy will contact me prior to continuing action on this request for my acceptance of the fee amount (if any).
Signature*

Clear
Relationship to Individual if not self
Should be Empty: