Get Walmart Authorization Form Revised Sept 2010.doc

Filling out the Walmart Authorization Form is a key step in managing your health information effectively. This guide will help you navigate each section of the form with confidence and clarity, ensuring that you complete it accurately online.

Follow the steps to fill out the Walmart Authorization Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. In Section 1, provide the patient's information, including their name, date of birth, address, city, state, zip code, and phone number.
3. In Section 2, specify the requestor's details. If the information is to be released to the patient, check the corresponding box and then continue to Section 3. Enter the individual or entity requesting the information, their address, city, state, zip, and phone number. Select the purpose of the release, ensuring to check the applicable box.
4. In Section 3, indicate what information you authorize to be released. Check all relevant boxes, including medical expenses summaries and the designated record set. If specific prescriptions need to be disclosed, detail them in the provided space. Specify the dates of service by either choosing all dates or entering specific ranges.
5. In Section 4, select the expiration date or event for this authorization. You may choose to have it valid until a certain date, until a specific event occurs, or for one year from the date of your signature.
6. Review Section 5 for understandings, ensuring you acknowledge the voluntary nature of the authorization and any rights associated with revoking it. You do not need to fill out this section; it serves as an agreement.
7. In Section 6, sign and date the form. If you are a personal representative, print your name and relationship to the patient in the spaces provided.
8. Once you have filled out all necessary sections, save your changes. You may choose to download, print, or share the completed form as needed.

Complete your Walmart Authorization Form online today for efficient management of your health information.