Get Individual Request Form/authorization For Release Of Pmp Report To ...

The Individual Request Form/Authorization For Release Of PMP Report To ... is an essential document for users seeking to authorize the release of their prescription monitoring data. This guide provides step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to successfully complete your form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, fill in the personal information of the individual requesting the report. Include their full name (first, middle, last), date of birth, address, phone number, city, state, and zip code.
3. Proceed to Section 2, labeled 'Release Information From'. Here, you need to confirm that the information is being released from the Minnesota Prescription Monitoring Program. Ensure you include the relevant address and contact details.
4. In Section 3, titled 'Release Information To', provide the details of the person or agency to whom the information is being released. This includes their name, agency, address, phone number, city, state, zip code, and email address. If there is a different mailing address, fill that in as well.
5. In Section 4, you will find the Explanation of Rights/Authorization for Release. Carefully read through the statements and tick the appropriate checkboxes confirming your understanding of your rights regarding the release of information.
6. You must sign and date the form in the designated area to authorize the release of your data. If you are not the individual requesting the information, ensure you indicate your relationship to the individual and understand if you are the legal guardian.
7. After completing all sections, you can proceed to save any changes made, download, print, or share the form as necessary.

Complete your Individual Request Form online to ensure a seamless request process.