Get Walmart Pharmacy Form

Filling out the Walmart Pharmacy Form online is a crucial step in authorizing the release of your health information. This guide will walk you through each section of the form, providing you with clear and detailed instructions to ensure that your submission is completed accurately.

Follow the steps to successfully complete the Walmart Pharmacy Form.

1. Press the ‘Get Form’ button to access the Walmart Pharmacy Form in your preferred editor.
2. Begin with Section 1 by providing your patient information, including your full name, address, date of birth, and phone number. Ensure that all details are accurate and match your identification.
3. In Section 2, specify the health information you wish to release. You can choose to authorize the release of specific prescriptions, a medical expense summary, or your entire medical record. Indicate the relevant dates of service or select 'All dates of service'.
4. List the facilities from which you want the information released. This can include all locations where prescriptions have been filled or specific locations of your choice. Be specific with the names and addresses.
5. Proceed to Section 3 to fill in the recipient's details, including their name, organization, phone number, and address. Clearly state the purpose of this authorization.
6. In Section 4, read through the specific consent regarding sensitive health information. You must initial the statement that applies to your authorization for releasing information concerning mental health or substance abuse.
7. If opting not to authorize the release of certain information, list the drugs and/or prescription numbers in Section 4(b) that should be excluded from your release.
8. In Section 5, determine the expiration date of the authorization. You can specify a date or indicate that it is valid for one year from your signature date.
9. Sign the form in Section 6, confirming that your authorization is voluntary and understand its implications. Provide the date, and if applicable, fill in your personal representative's details.
10. Finally, you have the option to check the box if you would like a copy of the signed form. After completing all sections, review the document for accuracy, then save changes, download, print, or share as needed.

Complete your Walmart Pharmacy Form online today for efficient processing of your health information.