Form 08-4598 - Patient Request For Record Correction Of Information In Prescription Drug Monitoring Program - Alaska Board Of Pharmacy

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PHA
T
S
HE 
TATE 
ALASKA 
of 
Department of Commerce, Community, and Economic Development
Division of Corporations, Business and Professional Licensing
Alaska Prescription Drug Monitoring Program
Board of Pharmacy
th
550 West 7
Avenue, Suite 1500
Anchorage, AK 99501
Phone: (907) 269-8404  Fax: (907) 269-6003
Email: akpdmp@alaska.gov
Website:
 
BoardofPharmacy/PrescriptionDrugMonitoringProgram.aspx
PATIENT REQUEST FOR RECORD CORRECTION
OF INFORMATION IN PRESCRIPTION
DRUG MONITORING PROGRAM
A patient may request that the Alaska Prescription Drug Monitoring Program (AKPDMP) correct any information about the
patient that is considered incorrect. The request must be made in writing. The patient request must state what specific
information in the report the patient considers incorrect. This would include the date the report was run, the date the
prescription was written and filled, and any other information to positively identify the record in question.
Instructions
Please provide the information requested below. (Print or Type) Use full legal name - not initials.
If this request is from an authorized agent, then please attach your proof of patient authorization or verification of
your authorized agent status.
AKPDMP staff will review the request and, if justified, will make changes to the database information
Mail this request and supporting document to:
Alaska State Board of Pharmacy
Alaska Prescription Drug Monitoring Program
th
550 West 7
Avenue, Suite 1500
Anchorage, AK 99501-3567
PLEASE COMPLETE ALL SECTIONS ON THIS FORM.
Full Name of Patient:
Date of Birth:
(mm/dd/yyy)
Physical Address of Patient:
Street
City
State
Zip Code
Previous Physical Address of Patient (if recently moved):
Street
City
State
Zip Code
Mailing Address of Patient:
Street
City
State
Zip Code
Date of Prescription:
Phone Number of Patient: (
)
08-4598
(Rev. 05/28/14)
Patient Request for Record Correction in PDMP page 1 of 2

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