Printable blank Walgreens Authorization Form

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What is Walgreens Authorization Form?

Walgreens Authorization Form is an official authorization application form of Walgreens that is designed for releasing information to a personal representative. It provides your relatives or other caregivers with access to your medical and health information to provide assistance on an on-going basis. Walgreens Authorization Form is not followed by other forms.

What I need the Walgreens Authorization Form for?

Walgreens Authorization Form:

  • Is needed for enabling a person to provide care to a patient for a limited period;
  • Is required if you want to become a personal representative of an ill person for a particular period;
  • Is not used for requesting Walgreens to release information to a third-party company. For that purpose, use “Authorization – For Release of Information to Third Parties”;
  • Should be filled if you apply for authorization for the first time as authorization can be rewoken.

The duration of the form can be defined by the applicant. You have to specify the expiry date in the form along with the date of signup.

Filling out Walgreens Authorization Form

In the first section, you should provide personal information of the patient. In the second, enter your personal information and define your relationship with the patient (spouse, parent, child, caregiver, etc.). In the 3rd box, list the information that has to be released and describe purposes in the 4th box. In section 5, specify the date of authorization expiration. In the next section, you are required to get acquainted with authorization rules and then sign the form to confirm that you allow Walgreens to use and disclose health information.

Organizations that work with Walgreens Authorization Form

Walgreens Privacy Office, Deerfield, Illinois.

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