Pharmacy and Vision Center/Optical Privacy Forms
You may return any of the completed forms to:
- Your local Walmart or Sam's Club Pharmacy or Vision Center/Optical location or,
- You may mail your requests to the addresses below.
Litigation-Related HIPAA Form Requests
Send any litigation-related Health Insurance Portability and Accountability Act (HIPAA) form requests to:
Trust Building - MS 0200
811 Excellence Dr
Bentonville, AR 72716-0200
All Other HIPAA Form Requests
Send any non-litigation-related HIPAA form requests to:
HIPAA Compliance
1 Customer Drive, Mailstop 0230
Bentonville, AR 72716
All requests are subject to the approval of Walmart Inc.
Form Downloads
You can download a copy of each form using the links below.
Request to Access Records
Use the Request To Access Records form to request copies of your Pharmacy or Vision Center/Optical records, including your medical expense summary for tax purposes.
Authorization to Release Health Information
Use the Authorization To Release Protected Health Information form to authorize another individual or third party to have access to part or all of your Pharmacy or Vision Center/Optical records.
Revocation of Authorization to Release Health Information
Use the Revocation of Authorization to Release Health Information form to revoke any authorizations that you have on file.
Request to Amend / Correct Health Information
Use the Request To Amend / Correct Protected Health Information form to request information be corrected in Pharmacy or Vision Center/Optical profile.
Request for Restrictions
Use the Request for Restrictions form to request additional restrictions regarding the use and disclosure of your health information.
Accounting of Disclosures Request
Use the Accounting of Disclosures Request form to request a copy of certain disclosures of your health information made by the Pharmacy or Vision Center/Optical.
Request for Confidential Communications
Use the Request for Confidential (Alternative) Communications form to request the Pharmacy or Vision Center/Optical communicate with you by an alternative address, phone number, or email address.
- I.e., if you wish to be called on your cell phone instead of your home phone, or would like mailings sent to your home address rather than your school address.
Authorization to Use/Disclose Protected Health Information for Media Purposes
Use Authorization to Use/Disclose Protected Health Information for Media Purposes to allow authorization of your records for the purposes of being used in the media.
Patient Health & Wellness Notices Acknowledgment
Use Patient Health & Welness Notices Acknowledgment to acknowledge that you have gotten the Health and Wellness notices.
Spanish Patient Health & Wellness Notices Acknowledgment
Use Spanish Patient Health & Welness Notices Acknowledgment to acknowledge that you have gotten the Health and Wellness notices and need the form in Spanish.
HIPAA Complaint Form
Use the HIPAA Complaint form if you feel that the privacy of your Pharmacy or Vision Center/Optical information hasn’t been handled in an appropriate manner. All complaints will be addressed in a timely manner.
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