Get Walmart Complaint Form

The Walmart Complaint Form is designed to help individuals submit complaints regarding the unauthorized use or disclosure of their protected health information. This guide will walk you through each section of the form to ensure you complete it accurately and effectively.

Follow the steps to fill out the Walmart Complaint Form online

1. Press the ‘Get Form’ button to access the Walmart Complaint Form and open it in your designated form editor.
2. Begin with Section 1: Patient Information. Here, enter the patient's name, date of birth, address, city, state, zip code, and phone number accurately to identify the individual associated with the complaint.
3. Proceed to Section 2: Complaint Section. In Part (a), select the relevant service area by checking the appropriate box for either Pharmacy, Vision Center/Optical, or Care Clinic, and provide the city and state where the incident occurred, along with the store number.
4. In Part (b), detail your complaint thoroughly. Be specific about patient names, dates, times, and the particular policies or procedures involved. If any relevant documents exist, attach them to support your claims. Utilize the reverse side of the form if additional space is needed.
5. Complete Section 3: Signature and Date. Print the name of the patient or the personal representative, provide a signature, and indicate the date of submission. If you are signing on behalf of the patient, specify your relationship in the provided space.
6. Once the form is completed, save any changes made. You may choose to download, print, or share the form as needed.

Don't hesitate to complete the Walmart Complaint Form online to address your concerns effectively.