Consumer Information

Full Name *

Address *

City *

State *

Zip *

Email Address *

Phone Number *

Authorized Agent

Are you submitting this request as an authorized agent for the above consumer? *

Yes No

Contact Preferences

How do you prefer we contact you regarding your request? (choose all that apply) *

Mail Email Phone

Request Type

What type of request are you making? *

Opt out of sale or sharing of personal information including health data Request to access the personal information maintained by the business Request to delete personal information Request to correct personal information Request to limit use of my sensitive personal information, including health data, and revoke consent for its use Appeal denial of a privacy request

Electronic Signature

By submitting this form, I give my electronic signature and certify under penalty of perjury that I am the above-named individual or a person authorized by the above-named individual to submit this form on their behalf. *