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Pharmacy: HIPAA Forms

Pharmacy Privacy Forms

You may return any of the completed forms to your local Walmart or Sam's Club Pharmacy, Vision Center/Optical, Care Clinic 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 Walmart Inc.


Request to Access Records

Use this form Opens in new window to request copies of your Pharmacy, Vision Center/Optical or Care Clinic records, including your medical expense summary for tax purposes.

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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, Vision Center/Optical or Care Clinic records.

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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 Pharmacy, Vision Center/Optical or Care Clinic profile.

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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.

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Accounting of Disclosures Request

Use this form Opens in new window to request a copy of certain disclosures of your health information made by the Pharmacy, Vision Center/Optical or Care Clinic.

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Request for Confidential Communications

Use this form Opens in new window to request the Pharmacy, Vision Center/Optical or Care Clinics 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).

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HIPAA Complaint Form

Use this form Opens in new window if you feel that the privacy of your Pharmacy, Vision Center/Optical, or Care Clinic 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

You will need Adobe Acrobat Reader to view the forms.

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