ALABAMA DEPARTMENT OF PUBLIC HEALTHPRESCRIPTION DRUG MONITORING PROGRAM

BUREAU OF PROFESSIONAL & SUPPORT SERVICESP.O. Box 303017

Montgomery, AL 36130-3017Office (334) 206-5226 Fax (334) 206-3749

www.adph.org/pdmp

**Office Use Only** _____/______/______

Date Received

LAW ENFORCEMENT DATABASE ACCESS REQUEST FORM

In accordance with Code of Ala. 1975 § 20-2-214, “state and local law enforcement authorities… authorizedto access prescription information upon application to the department accompanied by an affidavit stating

probable cause for the use of the requested information”.

All fields are required. Mail completed form to the address above.

Fax Number

City/County

APOST Certification Number

Zip/Postal Code

Phone Number

State

Address

Agency Information

Agency Name

Chief Law Enforcement Officer's Information

First Name Last Name

Title

Phone Number Fax Number

Email Address

Subscribed and sworn to before me this _________day of _______________________ 20_____________

Notary Public Seal

Notary Signature___________________________________________Date Commission Expires______________________________

Email Address

SSN DOB

Title

First Name Last Name

Officer's Information

Officer's Signature ________________________________________________________

Chief Law Enforcement Officer's Signature ___________________________________

Mail the following items to Prescription Drug Monitoring Program:Notarized Access Request Form

Signed Copy of the Privacy StatementCopy of Current Department/Agency ID

Copy of Current Driver's License