Get Request For Prescription Report - Representative Of ...

This guide provides clear instructions on how to fill out the REQUEST FOR PRESCRIPTION REPORT - REPRESENTATIVE OF ... online. By following these steps, you can successfully request prescription records on behalf of a patient you represent.

Follow the steps to complete your request for prescription records

1. Press the ‘Get Form’ button to access the REQUEST FOR PRESCRIPTION REPORT - REPRESENTATIVE OF ... and open it in the editor.
2. In the section labeled 'Information About the Patient,' fill in the patient’s full name including first, middle, last, and suffix in the provided fields.
3. Provide any other names the patient has used, including maiden names, married names, or alternative spellings in the 'Other Names Used' field.
4. Enter the patient’s date of birth in the format month/day/year and check the appropriate box for gender.
5. Complete the patient's mailing address, including city, state, zip code, and country.
6. Fill in the contact information including the patient’s phone number and email address.
7. Indicate the date range for the prescription records you are requesting, ensuring that the 'From' date is no earlier than 9/1/2011.
8. In the 'Information About Representation' section, check the box that best describes your relationship to the patient, and provide any additional explanation if necessary.
9. Complete your own mailing address and contact details in the respective fields.
10. Acknowledge your understanding of the legal implications associated with unauthorized access to prescription monitoring information by checking 'Yes' or 'No'.
11. Sign the affidavit certifying that you are the authorized representative and that all information provided is truthful.
12. Ensure the form is properly notarized and completed, as any unsigned, not notarized, or incomplete requests will be rejected.
13. Once completed, save any changes made to the document, then download, print, or share the form as necessary.

Complete your form online today to efficiently request prescription records.