If you wish to act as the designated caregiver for another individual, the patient must authorize you by completing the form below.
The form allows a patient to authorize their caregiver or another designated individual to discuss their medications and health condition with our staff. The purpose of this form is to let Walgreens and the specialty pharmacy staff know the patient’s decision and to protect their privacy and health information.
Once the patient has fully completed the form and signed it, please mail it to the Walgreens Privacy Office address as indicated on the form or fax it to 847-236-0862.
Adobe Reader is required to view PDF files.