[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283941-105":53,"doc-detail-283941-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","walmart-associates-medical-and-dental-plan-hipaa-authorization-form-participant-release-of-protected-health-information","Walmart Associates’ Medical and Dental Plan - HIPAA Authorization Form - Participant Release of Protected Health Information","","HIPAA authorization form for Walmart, Inc. associates’ medical and dental plan, enabling a participant to authorize the Plan and its business associates to release specified Protected Health Information (PHI) to a listed person, group, or organization. The form collects participant and recipient details, allows selection of all PHI or limited PHI with provider/date/diagnosis exceptions, and requires a reason for request plus signature. It states the authorization validity period, cancellation rights, and conditions regarding claims and benefits enrollment.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/walmart-associates-medical-and-dental-plan-hipaa-authorization-form-participant-release-of-protected-health-information/283941/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/walmart-associates-medical-and-dental-plan-hipaa-authorization-form-participant-release-of-protected-health-information/283941.png","ImageObject",442,249,{"name":88,"@type":89},"\tJames","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What does the authorization allow the Walmart Plan to do with my PHI?","Question",{"text":109,"@type":110},"It authorizes the Plan and its business associates to release Protected Health Information to the people, group, or organization listed on the form. The authorization covers the PHI described in the document.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Can I limit what PHI is released?",{"text":114,"@type":110},"Yes. You can mark either all my PHI or all my PHI except specific information. If you choose the exception option, you list the PHI details you do not want released and can attach additional pages if needed.",{"name":116,"@type":107,"acceptedAnswer":117},"How long is the authorization valid, and can it be canceled?",{"text":118,"@type":110},"The authorization is valid for one year from the date of your signature. You can cancel at any time by completing a Cancellation of Authorization Form, and written cancellation will not affect actions already taken in reliance on the authorization.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283941,1789966794,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},2336474466412,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Walmart, Inc. Associates’ Medical and Dental Plan – HIPAA Authorization Form  \nParticipant Release of Protected Health Information  \n\n| Participant Carrying Coverage Information\u003Cbr>Participant Whose PHI is Being Released | Name   Date of Birth   State where Participant lives   Identification Number   WIN  \u003Cbr>Name   Date of Birth   Address  \u003Cbr>Telephone Number   |\n| --- | --- |\n| AUTHORIZATION (The third party who will receive the participant’s Protected Health Information)\u003Cbr>I authorize the Walmart Inc. Associates’ Medical Plan and Dental Plan (the Plan), and its business associates to release Protected Health Information (PHI) to the people, group, or organization listed below:\u003Cbr>Full Name   Date of Birth (if available)  (person, group, organization other than self)\u003Cbr>Address  (person, group, or organization address needed for verification purposes) |  |\n| I authorize the Plan to release: (only mark one)\u003Cbr>All my PHI or All my PHI except:   If you have marked except, list the information (treatment for the dates of service, diagnosis (es)/condition(s), and/or\u003Cbr>treatment by the following provider(s) name/address) that you do not want released: (Attach additional pages if necessary) |  |\n| REASON FOR REQUEST:\u003Cbr>You may check the box below that states “At participant’s request” or you may specify below the reasons you are authorizing the Plan to share your PHI.\u003Cbr>At the participant’s request Other reasons (specify)   |  |\n| SIGNATURE\u003Cbr>I understand that:\u003Cbr>• This authorization is valid for one (1) year from the date of my signature.\u003Cbr>• I have the right to cancel this authorization at any time by completing a Cancellation of Authorization Form.\u003Cbr>• My written cancellation will not affect the ability of the Plan to use or disclose my PHI to the extent that it has already acted on reliance on this authorization.\u003Cbr>• I hereby authorize the use or disclosure of the PHI described in this authorization. I understand that if the person or entity that receives my PHI is not required to comply with the federal privacy regulations, the information would no longer be protected by those regulations.\u003Cbr>I understand that payment of my claims, my ability to enroll in the Plan or be eligible for benefits is not conditioned on my signing this authorization.\u003Cbr>Participant’s Signature (This is the Person whose PHI will be released) Date\u003Cbr>If you are authorizing the release of your own information, you are finished and it is not necessary to complete the below. If you have completed this form as a legally recognized representative of the participant it is necessary to complete the following:\u003Cbr>Name of Representative (Please print your name)   State your relationship to the participant (That allows you to act on their behalf)  \u003Cbr>Representative’s Signature (Sign this form on behalf of the participant) Date |  |\n\nAs required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Plan will obtain avalid, signed authorization from a Plan participant prior to using or releasing the participant’s Protected Health Information, unless the Plan participant’s authorization is not legally required by law.  \nReturn Form to:  \nMail Stop 3610-Benefits Total Rewards Team Attn: HIPAA Compliance Team  \n806 Excellence Drive Bentonville, AR 72716-3610  \n01305.01.01-v101625-0938  \n1209-5-1104f","cbCaiv8k8OuHNCOP","https://ap.wps.com/l/cbCaiv8k8OuHNCOP","pdf",61652,"English","# Participant information\n# Authorization and PHI release scope\n## Recipient details\n## What PHI to release\n# Reason for request\n# Signatures and cancellation rights\n# Submission address","[{\"question\":\"What does the authorization allow the Walmart Plan to do with my PHI?\",\"answer\":\"It authorizes the Plan and its business associates to release Protected Health Information to the people, group, or organization listed on the form. The authorization covers the PHI described in the document.\"},{\"question\":\"Can I limit what PHI is released?\",\"answer\":\"Yes. You can mark either all my PHI or all my PHI except specific information. If you choose the exception option, you list the PHI details you do not want released and can attach additional pages if needed.\"},{\"question\":\"How long is the authorization valid, and can it be canceled?\",\"answer\":\"The authorization is valid for one year from the date of your signature. You can cancel at any time by completing a Cancellation of Authorization Form, and written cancellation will not affect actions already taken in reliance on the authorization.\"}]","Walmart Associates’ Medical and Dental Plan - HIPAA Authorization Form - Participant Release of Protected Health Information | PDF",1789622898]