Privacy Forms

Here at NaturalMed Apothecary we take your personal health information seriously. Below are forms you need to request copies of your records or for other request when it comes to your PHI.

Printable Copy of Our Privacy Statement

• Request to Access Records
• Authorization to Release Health Information
• Revocation of Authorization to Release Health Information
• Request to Amend / Correct Health Information
• Request for Restrictions
• Accounting of Disclosures Request
• Request for Confidential Communications
• Pharmacy HIPAA Complaint Form

If you would like any of the above releases or request forms be placed on your file please fill out the nessary form and return any of the completed forms to us, or you may mail them to:

NaturalMed Apothecary, Inc.
Attn: Privacy Officer
212 N. Park Ave.
Herrin, IL 62948

All requests are subject to the approval of NaturalMed Apothecary, Inc. You will need Adobe Acrobat Reader to view the forms.

Download Adobe Acrobat Reader.