Request To Access, Inspect, Or Obtain Protected Health Information Form
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2Walgreens Custodian of Records, 1901 East Voorhees Street, MS 735, Danville, Illinois 61834
Fax: (217) 554-8955 Phone: (217) 554-8949
REQUEST TO ACCESS, INSPECT, OR OBTAIN PROTECTED HEALTH INFORMATION
Request:
I request to review health information held about me in the Walgreens “designated record set” in accordance with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
I understand that Walgreens has 30 days to respond to this request, Walgreens may extend this 30 day response period for another 30
days, and in certain circumstances Walgreens may deny my request.
Information:
Patient Name:
Date of Birth:
Street Address:
City, State, Zip
Telephone Number:
(
)
E-mail Address:
Standard requests for records contain a fifteen (15) month time period. If your request for records is in excess of fifteen (15) months,
please indicate the time frame below. Records are retained in accordance with State Board of Pharmacy, DEA, and other relevant laws
and vary from state to state.
From:
To:
I further request that my health information is directed to the third party at the address designated below.
Third Party Recipient :
Relationship:
Street Address:
City, State, Zip
Telephone Number:
(
)
E-mail Address:
Agreement:
I agree that Walgreens may provide a summary of health information instead of allowing me to review the information (check response
below):
Yes
No
Fee for Summary: ______________________
I agree to pay any fees for copying or summarizing my health information. Fees will be reasonable and cost-based, and include only
the cost of copying, postage, and preparation of a summary (if I agree to a summary).
I understand that this request does not apply to certain health information, including: (1) information that is not held in the designated
record set; (2) information compiled in reasonable anticipation of or for litigation; and (3) other information not subject to the right to
access information under HIPAA.
Signature:
Signature:
Date:
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