Forms- Request PMP History

Individual Report Request Form

An individual may request a copy of their own prescription history report by completing and submitting a request form. All forms must be signed in the presence of a notary public and submitted to the PMP office by mail, fax or email for processing.

Authorization to Release Report to a Third Party Form

An individual may request a copy of their own prescription history report be sent to a third party by completing a request form.  All forms must be signed in the presence of a notary public and submitted to the PMP office by mail, fax or email for processing.

Recipient Audit History Request Form

Allows a recipient (patient) to request an audit of the searches performed under their name/ date of birth for the previous 12 months. All forms must be signed in the presence of a notary public and submitted to the PMP office by mail, fax or email for processing.

Law Enforcement Request Form

Law Enforcement officials may request data by completing and submitting a request form. Please include, with the completed request form, only the valid search warrant.  Send to the PMP office by fax or email for processing. Please note: only previous 12 months of prescription data is retained for release.