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Privacy Act Personal Information Request Form

This form is to be used for personal information requests only. If you wish to submit a request for personal information, correction of personal information, deletion of personal information, or do not share personal information, please complete this form and click the SUBMIT button. The information requested on this form will be used for the purpose of completing your personal information request only and may be retained in accordance with our privacy policy or as dictated by law.

NOTE: You will not be able to submit this form to us until
ALL required fields have been entered.

*Denotes required fields

If required fields are not completed, request will not be processed.

First Name*

Last Name*


Business Name

Account Number


Address*

City*

State*

ZIP*

Phone Number*

Email Address*

  Check if you DO NOT HAVE an email address

*Please check the request you wish to submit:

  Personal Information Request
  Correction of Inaccurate Personal Information
  Deletion of Personal Information
  *If the request being submitted is for deletion of personal information, please check this box confirming you want your personal information deleted. See our Privacy Policy for details surrounding requests for deletion.
  Do Not Share Personal Information
  Consumer Health Data Request
  Appeal Request

* Please indicate how you would like to receive a response to this request:

  Email
  Postal Mail

  *By checking this box, I declare under penalty of all applicable Federal, State, and local laws that I am the subject named above and that all information I provided is accurate and true. I understand that any falsification of the information provided in this form maybe punishable under applicable Federal, State, and local laws by fine and/or imprisonment. I understand if this box is not checked and the required fields are not completed my request will not be processed.