Date

Your Name
Mailing Address
City, State, Zip

Re: Prescription Numbers __________, Request to Keep Prescription Information Private -- Do Not Share for Marketing Purposes

Name of Pharmacy
Mailing Address
City, State, Zip

Dear Pharmacist at _______________________:

Please do not use any of my personal information, including but not limited to my name, address, telephone number, name of medication and conditions of my use of that medication, for marketing, solicitations, or any other programs associated with pharmaceutical companies unless authorized in accordance with State law.

I look forward to your acknowledgement that you have received this notice by [date that is two weeks from date of letter].

Sincerely,

---------------------------------------
(Signature)

Your name