California Access/Deletion Web Form

If you are a California resident, the California Consumer Privacy Act (“CCPA”) provides you with certain rights with respect to your data. If you are a California resident, we have created the form below to assist you in submitting these requests. Please see our Privacy Policy for more information about how we collect and use information.

Type of request:*
- Provide me information about the categories of personal information you collect
- Provide me with the specific pieces of personal information you have collected about me
- Delete the personal information you have collected about me
Provide the below information necessary to process the request:*
First name Last name
Email address associated with your use of our services*
Address*
Address City State Zip code
- I would like to receive a copy of my medical record in connection with this request. I understand that my medical record is protected by health care data privacy laws specific to medical information. I consent to receive my medical record in an unencrypted electronic message.
I am making the request on behalf of:*
- Myself
- Someone else
If you’re making the request on behalf of someone else, please provide us with the following:*
Your first name Your last name
Your relationship to the consumer*
Upload authorization
Please upload a power of attorney, or written, signed form allowing you to submit the request on the consumer’s behalf. To complete this request we will also send an email to the consumer at the email provided above so that the consumer can verify their identity.

Accepted file types: pdf, jpg, png.
Certification*
I certify that I am a California resident and that all information I have submitted is true and accurate.