Walgreens Custodian Records Form PDF Details

A Walgreens custodian records form is a document that is filled out when a person is hired as a custodian at Walgreens. The form asks for basic information about the applicant, such as name and address, as well as their qualifications for the job. The form also asks whether the applicant has ever been convicted of a crime. This document is an important tool for employers in screening potential employees. It can help them to determine whether an applicant is qualified for the position and has a clean criminal record.

Here is the details about the form you were in search of to fill out. It will show you the length of time you'll need to complete walgreens custodian records form, what parts you will need to fill in, etc.

QuestionAnswer
Form NameWalgreens Custodian Records Form
Form Length2 pages
Fillable?Yes
Fillable fields20
Avg. time to fill out4 min 34 sec
Other nameswalgreens custodian of records address, walgreens custodian of records email address, walgreens records, my records walgreens

Form Preview Example

Walgreens Custodian of Records, 1901 East Voorhees Street, MS 735, Danville, Illinois 61834

Fax: (217) 554-8955 Phone: (217) 554-8949

REQUEST TO ACCESS, INSPECT, OR OBTAIN PROTECTED HEALTH INFORMATION

Request:

I request to review health information held about me in the Walgreens “designated record set” in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I understand that Walgreens has 30 days to respond to this request, Walgreens may extend this 30 day response period for another 30 days, and in certain circumstances Walgreens may deny my request.

Information:

Patient Name:

Date of Birth:

Street Address:

City, State, Zip

Telephone Number:

(

)

E-mail Address:

Standard requests for records contain a fifteen (15) month time period. If your request for records is in excess of fifteen (15) months, please indicate the time frame below. Records are retained in accordance with State Board of Pharmacy, DEA, and other relevant laws and vary from state to state.

From:To:

I further request that my health information is directed to the third party at the address designated below.

Third Party Recipient :

Relationship:

Street Address:

City, State, Zip

Telephone Number:

(

)

E-mail Address:

Agreement:

I agree that Walgreens may provide a summary of health information instead of allowing me to review the information (check response below):

Yes

No Fee for Summary: ______________________

I agree to pay any fees for copying or summarizing my health information. Fees will be reasonable and cost-based, and include only the cost of copying, postage, and preparation of a summary (if I agree to a summary).

I understand that this request does not apply to certain health information, including: (1) information that is not held in the designated record set; (2) information compiled in reasonable anticipation of or for litigation; and (3) other information not subject to the right to access information under HIPAA.

Signature:

Signature:

 

Date:

Walgreens Custodian of Records, 1901 East Voorhees Street, MS 735, Danville, Illinois 61834

Fax: (217) 554-8955 Phone: (217) 554-8949

If signed by the patient’s personal representative, explain authority to act on behalf of the patient:

Note: If you are signing this form as the legal representative of the individual listed above, and are other than the parent of the minor child whose information is listed above, you must also submit documentation that establishes yourself as the legal representative. For example, a copy of a Power of Attorney that includes provisions to obtain medical information, etc.

Method for receiving your health information: (check only one box below)

Paper

Email (Encrypted) In an effort to protect your health information, our standard practice is to encrypt our email.

Email (Unencrypted) Signature Required. By signing you acknowledge that you understand an unencryped email exposes your personal and health information to additional security risks. Signature______________________________

If you require your health information in a format other than paper or email, please contact us at the number listed above. We may be able to accommodate your request at an additional charge.

Records from other Walgreens entities:

Please contact us if you need to receive records from other Walgreens entities.

How to Edit Walgreens Custodian Records Form Online for Free

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All of the following parts are going to make up the PDF form:

custodian of records walgreens fields to complete

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