Authorization for Release of Medical Records

Hy-Vee
Obtaining Your Medical Records
You can get your pharmacy records online at www.hy-vee.com by creating an account and then click on Health & Pharmacy/Pharmacy/My Pharmacy/Order History & Reports here. There you can put in a date range and then view and print your report. If you are not able to do that, then please complete the form below. If you have any questions please call: (515) 267-7736. You will reach a voicemail box for Datavant - our vendor who handles these requests.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
DOB MM
DOB DD
DOB YY
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize Hy-Vee Pharmacy to provide me with copies of my personal health information as indicated below covering the dates of:
Start Date*

MonthDayYear
End Date*

MonthDayYear
Start MM
Start DD
Start YY
End MM
End DD
End YY
Records to be released to:*

SelfParent/GuardianPower of AttorneyA company, business, or organization
If releasing records to a company, business, or organization other than the patient please provide the name of the recipient
Reason for Request*

MovingLegalLife InsuranceMilitary RequestTransferring CareOther
Preferred Method of Distribution*

US MailEmail
Email to send records to
Is mailing address for records different than patient address?

YesNo
Mailing Address to send Records to (if applicable and different than your home address)
Information to be released*

Medical RecordsBilling RecordsOther
Patient Phone Number to Contact with Questions*
You may get an email from our vendor, Datavant. Federal law allows and we do charge cost-based expense for records in some cases. If applicable, these charges must be paid before records are released. We will reach out to you if this applies to your record request at the phone number you listed above.
By signing below you agree to the following:

I authorize Hy-Vee to release the records listed above, for the dates listed above, via email or U.S. Mail as listed above.

I understand that Hy-Vee does not maintain records regarding mental health, substance abuse treatment. AIDS related information and genetic information may be included in my record and will be released unless specifically noted otherwise.

I understand this authorization is valid for one year, unless I notify Hy-Vee in writing to revoke this authorization. However, I do understand a revocation of authorization will have no impact on any records already released.

I understand that the information disclosed may be re-disclosed by the person or entity receiving it, at my request, and then would no longer be protected by federal privacy regulations.

I attest that I am authorized to request and receive the records requested on this form.
Signature*

Clear
Date of Signature*

MonthDayYear
Date
Signature MM
Signature DD
Signature YY
Relationship to Patient*

SelfParent/GuardianPower of Attorney
Upload POA documentation. This must be received before processing.

Only PDF files accepted
Cancelof
Should be Empty:

Obtaining Your Medical Records