Pharmacy

Pharmacy Records

Prescription fill history, medication records

Common uses

•Medication reconciliation
•Insurance claims
•Disability applications

How to find the fax number

Pharmacy chains (CVS, Walgreens, Rite Aid, etc.) have pharmacy records fax lines. Ask your pharmacist for the records release fax number at your specific location.

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Request Records — Pharmacy Records

Select a template, complete the patient information fields, enter the provider fax number, and send.

Choose a template

Subject: Request for Release of Medical Records — [PATIENT_NAME]

Authorization text

Replace all [BRACKETS] before sending

Authorization for Release of Health Information (HIPAA Compliant)

To the Medical Records / Health Information Management Department,

PATIENT INFORMATION
Patient Full Name: [PATIENT_NAME]
Date of Birth: [DATE_OF_BIRTH]
Last 4 SSN (optional): [SSN_LAST_4]
Address on file: [PATIENT_ADDRESS]
Phone: [PATIENT_PHONE]

RECORDS REQUESTED
Dates of Service: [DATE_RANGE — e.g., 01/01/2023 to 12/31/2024]
Type of Records: [RECORD_TYPES — e.g., complete medical record, office visit notes, lab results, imaging reports, operative reports, discharge summaries]
Specific Provider / Department: [PROVIDER_OR_DEPT — if applicable]

PURPOSE OF REQUEST
[PURPOSE — e.g., Continuity of care with new provider, insurance claim, disability application, personal records, legal proceeding]

RELEASE TO (send records to)
Name / Organization: [RECIPIENT_NAME]
Fax: [RECIPIENT_FAX]
Address: [RECIPIENT_ADDRESS]

AUTHORIZATION
I understand that I have the right to revoke this authorization in writing at any time except to the extent that action has already been taken. This authorization will expire: [EXPIRATION — e.g., 90 days from today, or upon completion of the request].

I understand that the records released may include information about mental health, substance use, HIV/AIDS, or other sensitive conditions, and I specifically authorize their release.

Signature: ____________________________
Printed Name: [PATIENT_NAME]
Date: [TODAY_DATE]
Relationship to Patient: [SELF / Guardian / Legal Representative]

Please send records to the fax number shown above. If you require an original signature or specific form, please fax your requirements to [YOUR_FAX_NUMBER]. Under HIPAA, you must respond to valid record requests within 30 days.

Thank you for your prompt assistance.

⚠️ 17 unfilled fields remaining: [PATIENT_NAME], [DATE_OF_BIRTH], [SSN_LAST_4]…

Provider fax number *

Pharmacy chains (CVS, Walgreens, Rite Aid, etc.) have pharmacy records fax lines. Ask your pharmacist for the records release fax number at your specific location.

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