Walmart and Sam’s Club Pharmacy and Vision Center/Optical HIPAA forms

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 HIPAA form requests to:

Walmart-HIPAA Authorizations/Subpoenas
702 SW 8th Street
Mail Stop 0215
Bentonville, AR 72716-0215

All Other HIPAA Form Requests

Send any non-litigation-related HIPAA form requests to:

Walmart - HIPAA Privacy
2608 SE J Street, Suite 8
Mail Stop 0230
Bentonville, AR 72716-0230

All requests are subject to the approval of Walmart Inc.

Form Downloads

You can download a copy of each form by clicking on its name in the list 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 or phone number (i.e., if you wish to be called on your cell phone instead of your home phone, or would like any mailings to be sent to your home address rather than your school address).

HIPAA Complaint Form 
Use the HIPAA Complaint form if you feel that the privacy of your Pharmacy or Vision Center/Optical information has not been handled in an appropriate manner. All complaints will be addressed in a timely manner.

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