Privacy Form

Select State Main Panel
CA Panel
VA Panel
CO Panel
CT Panel
UT Panel
WA Panel
NV Panel
TX Panel
MT Panel
OR Panel

Select State Main Panel
CA Panel
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VA Panel
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CO Panel
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CT Panel
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UT Panel
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WA Panel
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NV Panel
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TX Panel
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MT Panel
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OR Panel
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Select Your State*

Select the state that is applicable to your request.

Step1
Step2

California CCPA Form

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Relationship to the Resident

Please select one:

Self

Authorized Agent

Proof Of Authorization*

Allowable forms of authorization include: Power of attorney, documentation of guardianship, conservatorship, or other acceptable legal documents

Choose File

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please select at least one form of identification (Required)

Social Security Number

Employee ID

Social Security Number

Employee ID

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Verification Information*

Please select at least one form of identification (Required)

Social Security Number

Tax ID

National Producer Number

Insurance License Number

Social Security number

Tax ID

National Producer Number

Insurance License Number

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Verification Information*

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number

Employee ID

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Verification Information*

Social Security Number

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Verification Information*

User Name

Verification Information*

Workers’ Compensation Case Number*

Verification Information*

Please provide the following information (Required)

License Or Certification Number To Practice In Your State

National Provider Identifier (NPI) Number

Council For Affordable Quality Healthcare (CAQH) Number

Step1
Step2

Virginia Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Step1
Step2

Colorado Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Relationship to the Resident

Please select one:

Self

Authorized Agent

Proof Of Authorization*

Allowable forms of authorization include: Power of attorney, documentation of guardianship, conservatorship, or other acceptable legal documents

Choose File

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Step1
Step2

Connecticut Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Relationship to the Resident

Please select one:

Self

Authorized Agent

Proof Of Authorization*

Allowable forms of authorization include: Power of attorney, documentation of guardianship, conservatorship, or other acceptable legal documents

Choose File

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Step1
Step2

Utah Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Relationship to the Resident

Please select one:

Self

Authorized Agent

Proof Of Authorization*

Allowable forms of authorization include: Power of attorney, documentation of guardianship, conservatorship, or other acceptable legal documents

Choose File

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Step1
Step2

Washington Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Relationship to the Resident

Please select one:

Self

Authorized Agent

Proof Of Authorization*

Allowable forms of authorization include: Power of attorney, documentation of guardianship, conservatorship, or other acceptable legal documents

Choose File

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Step1
Step2

Nevada Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Step1
Step2

Texas Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Relationship to the Resident

Please select one:

Self

Authorized Agent

Proof Of Authorization*

Allowable forms of authorization include: Power of attorney, documentation of guardianship, conservatorship, or other acceptable legal documents

Choose File

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Step1
Step2

Texas Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Relationship to the Resident

Please select one:

Self

Authorized Agent

Proof Of Authorization*

Allowable forms of authorization include: Power of attorney, documentation of guardianship, conservatorship, or other acceptable legal documents

Choose File

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

Step1
Step2

Oregon Form Fragment

Resident Type*

Select the Resident Type that applies to you.

Request Type*

Select the type of request you're making.*

Please select one:

I want to know the personal information that has been collected, used, and/or disclosed.

I want the following specific personal information in order to transfer it.

What personal information should be corrected?

Email Address*

Your requested personal information will be sent via secure email.

Please list the specific personal information you are requesting

Select your business relationship with us.*

Step2

Relationship to the Resident

Please select one:

Self

Authorized Agent

Proof Of Authorization*

Allowable forms of authorization include: Power of attorney, documentation of guardianship, conservatorship, or other acceptable legal documents

Choose File

Resident’s Personal Information*

First Name*

Last Name*

Date of Birth*

Guardian Name (Required If 12 Or Under)

Address*

Suite, Apt. etc.

City*

State*

ZIP Code*

+4 Code

Phone*

Home Phone

Mobile Phone

Work Phone

May we call you at this number if we have questions or need additional information?

Yes

Verification Information*

Please provide the following information (Required)

User Name

Verification Information*

Please select at least one form of identification (Required)

U.S. Domain ID

Social Security Number

Employee ID

U.S. Domain ID*

Social Security Number*

Employee ID*

Personal Information (Including Social Security Number) Privacy Protection Policy

Your privacy is very important to us and we will make every reasonable effort to safeguard any information we collect. Visit the privacy link in the footer to learn more.

State Consumer Privacy Law Request Form

Please use this form to submit requests regarding your personal information, in accordance with your state’s consumer privacy laws (where applicable).