To Receive Your Medication Expenditures:
Your must fill out the Right to Access and Consent for Release of Protected Health Information Form
POLICY: In the case of a verbal or written request for PHI included in the Pharmacy’s Medical Expense and Accounts Receivable Information, the Pharmacy may (at the discretion of the Pharmacist, Privacy Officer, bookkeeper or person receiving a written or verbal request) release patient specific information limited to as included in it’s then current Medical Expense and/or Accounts Receivable Information directly to the patient or authorized agent of the patient without having the release herein previously completed.
PURPOSE: In any case where the requested information goes beyond the Pharmacy’s then current Medical Expense and/or Accounts Receivable Information or a Pharmacy employee believes the patient’s PHI is best protected by having the release herein completed prior to release of any PHI, this release serves as the documented request for the release of Protected Health Information (PHI) to the patient or authorized agent of the patient as designated below.
*Mail your completed release form to:
8 S. Main S.
Clintonville, WI 54929
PHARMACY: (715) 823-2222
PHARMACY FAX: (715) 823-6000