---
title: PHI from Pharmacy
description: Michigan Legal Copy Forms for the release of protected health information from a Michigan area pharmacy.
---

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# Forms for PHI from a Pharmacy

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### Costco Authorization to Release PHI

Click the button below to access the form

[![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502727.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLJCoBDPvCTMFB4X1AWTh5bUVRo0zFAhA7THYJV2N8lf6Ktk66w2YAP9n0HZTl0it2NJkBsdqDg%2FU034w2jOKmFYtD%2B2h5E6J9gBC07%2FmovW%2BR7KvI7705k65dsZAOzcVqFWiFKnziBvIqts25KRHZF9chPlwLcFK5gmnm2HHopk12IVl3W2gnSb422Hxpe0JMRMhjc%2BjvPezhbA6aZl4SvhOw%2FgUx4qM8HPf4ZC3XifKcu7Tj3CLsY%3D&webInteractiveContentId=196597502727&portalId=5105050)

**

### Express Scripts, Inc.- Authorization to Release Prescription Records

Click the button below to access the form

[![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669321.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLKJhCyOLdnvE%2F627SaTLATUoxv360PekDqaQXSKDZp3FfZYMNo9YxAoj0tA2glqL4nG52Vj1BmDCpq5TXRJ3mYiMAkZ9Pe2qY46gAYKZJq7SlBFO7svINRUyHgUYdWHwLycYHxBNSVJqBAzjufOMEE%2BvbKiBDfL7%2FLb6xVb2fXVcph29EBmvO7eW%2B9PMQg2j4gWZJ6whAGMJ55gNrS4fFRz5%2FKuXM6ORlLj0BhGSFywwe9pMRo%2B80Y%3D&webInteractiveContentId=196599669321&portalId=5105050)

**

### Meijer Pharmacy- Authorization to Release Records

Click the button below to access the form

[![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669329.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLJNDXrLDoQ0f1ay1i5ST%2FUcjCHQrUU7aOQzcD%2BNKLcfs0uvZ5KymdC4KB3T399fqxx%2BPc5lGI33OVcyBe%2BcTgxyJRyAcASZ6pK61feJe5ktaIn1ymDhA%2Fm%2BaBlYtwiB1MLjTSTxvu1%2B6GufbsS8BoLF%2B6s3yyfxTN2jCsYkckWW4dgm7dboQmJX3d%2BEw%2B%2BjPrLMpZgdtXLA4sefp7qIL%2Fj4Bc%2F47e6M%2BESdIyUAqp4oUIPX51dlBTM%3D&webInteractiveContentId=196599669329&portalId=5105050)

**

### Rite Aid Authorization to Release PHI

Click the button below to access the form

[![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669348.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLKgoWDSnlzqlYBCMnl8HXvHPCL9C9M3DeTC6X6YTmwDkLfrLF9OpBOgkjDdYMvkQd%2BbsiU7XzAjqq%2B38YwdaSqt9gxw7KQo%2BSVuaX1REz1%2BWoEi2HlRRw7Ir2OFxUAZwu%2B5lpVmmSd0tOBeNzwDJEbYtPm5pFwK7V80p8zTFjATE%2BggCkf%2BSIQpZE%2B0LTRrIFXK%2F%2Bk7ci9XzfBjrsys%2Fx1ZFTspTi0i60olBkHH0rkQ4ndxS7rVJgY%3D&webInteractiveContentId=196599669348&portalId=5105050)

**

### SpartanNash- Authorization for Release of Patient Information

Click the button below to access the form

[![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669365.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLIF14rHvHX8ntKrXazzI1HVSs9qZFbSCpY1WMkChclwW5wy6d5daeJq3SoMy9iTRl91Hp1noMg7%2FAG1Gi96X5PL%2BdzyLo1ka4E0nsPctlgNUNxQcn%2FMMIdOxbGSJCOAlr4YwKMDelYlnFct7sFa4e1OOjBHBOTzTJ5GdqLd47ZfLFxGQ%2B%2BoAz5lJYHWXol3vvH1tzMbn4rcqPD7AuLn%2BhLL0FpIEQdTOnyv1GfCgpUJ6MmcUwLUHm8%3D&webInteractiveContentId=196599669365&portalId=5105050)

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