Request a Copy of Your Prescription Records

You have the right to obtain a copy of your prescription records (subject to certain limitations), and to request that your records be provided to someone else (again, subject to certain limitations).  In order to protect your privacy, we must have your written permission before releasing the records.

To request a copy of your prescription records:

1. Print a copy of the Authorization for Release of Health Information form 
   (Autorización para Divulgar Datos de la Salud)
2. Complete the entire form
   (Incomplete forms may be returned to you for completion.)
3. Sign and date the form
   (Information cannot be released without a signature and date)
4. If you are the healthcare agent, court appointed guardian, holder of a medical power of attorney or similar legally appointed representative, please attach proof of your authority to act on behalf of the patient.
5. Please return the completed form (and any attachments) via mail, fax, or in person to one of the Outpatient Pharmacy locations.
6. Please allow at least 2 weeks for processing.
7. For questions or concerns about the request please contact the Patient Information Center at 410-288-4630 or 410-288-8174

Mail or fax the form to:

Fax: 410-288-0158