Hopkins Center Drug

Patient Forms

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.)

COVID-19 Vaccine Registration Form

Fill out this form and bring it with you when you come to get your COVID-19 Vaccine. Open form

Flu Vaccine Registration Form

Fill out this form and bring it with you when you come to get your flu shot. Open form

RSV / Pnuemonia / Shringrix / Tdap Vaccine Registration Form

Fill out this form and bring it with you when you come to get your vaccine. Open form

Patient Records Access Request Form.

Obtain a list of medications / tax-insurance printout for a person. Open form

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). Open form

Amend Records Request Form

Use this form to request any amendment to your Protected Health Information (PHI). Open form

Nursing Home Patient Enrollment Form

Use this form to submit nursing home patient enrollment information. Open form

HIPAA Release for any Medical Information

Use this form for HIPAA release of any medical information. Open form

HIPAA Release to Mail Account Statement to another party

Use this form for HIPAA release to mail account statement to another person. Open form