Connect With Us
Select the form to wish to use, then click the open form button to view it.
(You must fill out a separate form for each person you are retrieving information for, sign it, and either fax it or bring it into the store.)
Flu Vaccine Registration Form
Fill out this form and bring it with you when you come to get your flu shot.
Patient Records Access Request Form.
Obtain a list of medications / tax-insurance printout for a person.
Additional Restrictions Request Form
Use this form to request any additional restrictions you would like placed on the uses and disclosures of your Protected Health Information (PHI).
Amend Records Request Form
Use this form to request any amendment to your Protected Health Information (PHI).
Nursing Home Patient Enrollment Form
Use this form to submit nursing home patient enrollment information.
HIPAA Release for any Medical Information
Use this form for HIPAA release of any medical information.
HIPAA Release to Mail Account Statement to another party
Use this form for HIPAA release to mail account statement to another person.