Request Forms for Prescription Monitoring Data

The Prescription Monitoring Program is a part of the Massachusetts Drug Control Program database and includes data for all federal (and specified state) prescriptions dispensed in the state and to residents from out of state mail order pharmacies. Massachusetts General Law allows for certain Healthcare Providers, Patients, Researchers and Third-Party Authorization Data requests PMP data.

Prescriber Data Request Form

Note: Authorized users of MassPAT can obtain their most recent two years of their prescribing history by logging in and running their “MyRx” report.  Data requests beyond two years, you will need to fill out the data request form and send to the Department as instructed below.

Instructions for completing the Prescriber Data Request form:

• All sections must be completed.  Incomplete Data Request Forms will not be processed.
• A photocopy of your picture ID is required.
• Completed form must be faxed to [phone] or mailed to:
  
  Massachusetts Prescription Monitoring Program
  100 Cambridge St., 19th Floor
  Boston, MA 02114-2509

Please do not email this form.

Personal Data Request Form

Patients seeking their own controlled substance prescription history can do so by completing the Personal Data Request Form as instructed below.

Instructions for completing the Personal Data Request form:

• All sections must be completed.  Incomplete Data Request Forms will not be processed.
• A photocopy of your picture ID is required.
• Completed form must be faxed to [phone] or mailed to:
  
  Massachusetts Prescription Monitoring Program
  100 Cambridge St., 19th Floor
  Boston, MA 02114-2509

Please do not email this form.

Third Party Authorization Data Request Form

FIPA (Fair Information Practices Act.  M.G.L. c. 66A) authorizes a person to request the data of another person when a parent or guardian requests the data of a minor child, when the requestor has the data subject’s (Patient’s) power of attorney, or when the requestor has a court appointment as an estate administrator or executor for that person.  If you do not have this kind of relationship to the person whose records you are requesting, you cannot gain access to records. If you are legal counsel seeking to make a data request, please contact the Program at [e-mail] for guidance.

Checklist for required documentation:

• If you are a parent or guardian requesting the PMP data of a minor:
  • Copy of your government issue photo ID  and 
  • Copy of birth certificate of minor showing your relationship  or Copy of guardianship papers showing your relation to the minor.
• If you are requesting the PMP data of an adult:
  • Copy of your government issue photo ID  and   
  • Copy of document proving power of attorney of the person whose data you are requesting or
  • Copy of document proving court appointment as personal representative, estate administrator, or executor for the person whose data you are requesting.

Instructions for completing the form:

• All sections must be completed.  Incomplete Data Request Forms will not be processed.
• Request form must be signed and dated.
• Completed form must be faxed to [phone] or mailed to:
  
  Massachusetts Prescription Monitoring Program
  100 Cambridge St., 19th Floor
  Boston, MA 02114-2509

Please do not email this form.

Prescription Monitoring Program (PMP) De-identified Data Request Form

The Commissioner or designee may provide de-identified data to a public or private entity for statistical research or educational purposes. M.G.L. c. 94C, §24A

Checklist for competing the data request form:

• All sections must be completed unless otherwise indicated. Incomplete Data Request Forms will not be processed.
• All completed Data Request Forms must be signed, scanned, and submitted by email (recommended) to: [e-mail],  or submitted by mail to the address noted above. 
• Find more information on the Massachusetts Prescription Monitoring Program at www.mass.gov/dph/dcp/pmp

Massachusetts Prescription Monitoring Program
100 Cambridge St., 19th Floor
Boston, MA 02114-2509

Date published:	April 19, 2023