Request To Access, Inspect, Or Obtain Protected Health Information Form Page 2

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Walgreens Custodian of Records, 1901 East Voorhees Street, MS 735, Danville, Illinois 61834
Fax: (217) 554-8955 Phone: (217) 554-8949
If signed by the patient’s personal representative, explain authority to act on behalf of the patient:
Note: If you are signing this form as the legal representative of the individual listed above, and are other than the parent of the minor
child whose information is listed above, you must also submit documentation that establishes yourself as the legal representative. For
example, a copy of a Power of Attorney that includes provisions to obtain medical information, etc.
Method for receiving your health information: (check only one box below)
 Paper
 Email (Encrypted) In an effort to protect your health information, our standard practice is to encrypt our email.
 Email (Unencrypted) Signature Required. By signing you acknowledge that you understand an unencryped email exposes your
personal and health information to additional security risks. Signature______________________________
If you require your health information in a format other than paper or email, please contact us at the number listed above. We may be
able to accommodate your request at an additional charge.
Records from other Walgreens entities:
Please contact us if you need to receive records from other Walgreens entities.

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