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Walmart.com Help: Pharmacy: Privacy Forms

Pharmacy Privacy Forms

You may return any of the completed forms to your local Walmart or SAM'S CLUB Pharmacy location, or you may mail your requests to:

Health & Wellness HIPAA Privacy
702 SW 8th Street
Bentonville, AR 72716-0230

All requests are subject to the approval of Wal-Mart Stores, Inc.


  1. Request to Access Records Moves to another location on this page
  2. Authorization to Release Health Information Moves to another location on this page
  3. Revocation of Authorization to Release Health Information Moves to another location on this page
  4. Request to Amend / Correct Health Information Moves to another location on this page
  5. Request for Restrictions Moves to another location on this page
  6. Accounting of Disclosures Request Moves to another location on this page
  7. Request for Confidential Communications Moves to another location on this page
  8. Pharmacy HIPAA Complaint Form Moves to another location on this page
  9. Download Adobe Reader Moves to another location on this page

Request to Access Records

Use this form Opens in new window to request copies of your Pharmacy records, including your medical expense summary for tax purposes. Please note, if you are requesting records for anyone other than yourself, the Pharmacy must have documentation that you are authorized to request the patient's records (e.g., guardianship papers, power of attorney, proof of parent-child relationship, or an authorization form completed by the patient).

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Authorization to Release Health Information

Opens in new window Use this form to authorize another individual or third party to have access to part or all of your Pharmacy records (i.e., you would like your spouse to pick up your Pharmacy records). The Authorization would remain in effect until the expiration date of your choice, or until you revoke the Authorization.

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Revocation of Authorization to Release Health Information

Use this form Opens in new window to revoke any Authorizations that you have on file.

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Request to Amend / Correct Health Information

Use this form Opens in new window to request information be corrected in your Pharmacy profile. Please note, the Pharmacy cannot change information provided by a doctor's office, or change information that is accurate and complete.

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Request for Restrictions

Use this form Opens in new window to request additional restrictions regarding the use and disclosure of your health information. When completing the "Request for Restrictions," keep in mind that it may be necessary to disclose your health care information in certain situations. Some of these instances include releasing health information as required by law, for payment of your prescription claims and for health care oversight activities.

We are unable to grant broad request for additional restrictions to health care information, such as "Don't disclose my health care information to anyone," or "No disclosures without my written permission." All reasonable requests to limit release of your health information will be considered. You will be notified in writing of the Pharmacy's decision to accept or deny your restriction request. Until a decision is reached, your request for restriction will not be honored.

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Accounting of Disclosures Request

Use this form Opens in new window to request a copy of any disclosures of your health information made by the Walmart or SAM'S CLUB Pharmacies. The list may not include certain disclosures including, but not limited to, those we have made for our treatment, payment and health care operations purposes, those that are incidental to another permissible use or disclosure, those made under an Authorization provided by you, those made directly to you or to your family or friends, or for disaster relief purposes. The list also may not include disclosures we have made for national security purposes or to law enforcement personnel, or disclosures made before April 14, 2003.

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Request for Confidential Communications

Use this form Opens in new window to request the Walmart or SAM'S CLUB Pharmacies communicate with you by an alternative address or phone number (i.e., if you wish to be called on your cell phone instead of your home phone, or would like any mailings to be sent to your home address rather than your school address). Your request may be denied if it cannot reasonably be accommodated.

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Pharmacy HIPAA Complaint Form

Use this form Opens in new window if you feel that the Privacy of your Pharmacy information has not been handled in an appropriate manner. All complaints will be addressed in a timely manner.

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Download Adobe Reader


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