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Request to Access Records Cover Sheet - Walmart.com

Request for: Pharmacy Information Vision Center/Optical Information Care Clinic What is the purpose of the Request ? This form allows you to Request your Protected Health Information ( PHI ). You and your personal representative have a right to Request a copy of your PHI maintained by Walmart and Sam s Club Pharmacies, Vision Centers/Opticals or Care Clinics (collectively Walmart ). Legal Authorization for the Request is required and must be faxed to Walmart Legal at 479-204-9696 along with this Cover Sheet . The Request may be denied by Walmart under certain circumstances.

Authorization for the request is required and must be faxed to Walmart Legal at 479-204-9696 along with this cover sheet. The request may be denied by Walmart under certain circumstances. Your request will be acted upon within 30 days unless Walmart provides notification in writing that an extension of up to 30 days is needed.

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