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

[email protected]

Please mark the records you are requesting access to:*

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*

Relationship to Individual if not self