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Acknowledgement and Authorization

Dierbergs Markets is committed to maintaining the privacy of your Protected Health Information (PHI), while providing high quality medical care. In accordance with the Health Insurance Portability and Accountability Act of 1996, today we are presenting to you a full written notice of our privacy practices (v1.0).

Please read the entire document at your convenience. Dierbergs' Pharmacy will not condition any services on the basis of your refusal to sign this authorization. Should you have questions please feel free to contact either the pharmacist or Dierbergs' Privacy Official at
(636) 532-8884.

I hereby authorize Dierbergs Markets, Inc. to disclose my PHI consistent with federal & state law and their policies.

Authorization:


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Please print out this page using your browser's print option, sign it and mail to:

Dierbergs Privacy Officer
16690 Swingley Ridge Road
Chesterfield, MO, 63017
Dierbergs Pharmacy Portal
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Pharmacy Portal

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Automated Refill Service
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