Prescription Release Records

You have the right to obtain a copy of your prescription records and to request that your records be provided to an alternate individual. In order to protect your privacy, we must have your written permission before releasing the records

To request a copy of your prescription records:

Prescription Release Form
  1. Print a copy of the LifeBridge Health Medical Information Form
  2. Complete the form and include your contact information.
    - Please check other indicate “prescription records”
    - List time frames for the prescription records that you are requesting
    - Please note that the above information must be completed to fulfill a request
  3. Sign and date the form
  4. Please return the completed form via mail, fax, or in person to the Outpatient pharmacy.
  5. Please allow one week for processing.
  6. For questions or concerns about the request please contact the Pharmacy at 410-701-4455

Mail or fax the form to:

The LifeBridge Pharmacy at Northwest Hospital
Attn: Retail Pharmacy
5401 Old court road
Randallstown, MD 21133
Fax: 410-701-4422