Privacy Rights Request Form | Access, Correct or Delete Data

Privacy Rights Request

Full Name *

Email Address *

Phone Number

State of Residence *

Select the type of privacy request *

Details of Request *

Submitting this Request

Yes

No, I am an authorized agent

Name of person you represent

Relationship to person

Proof of authorization upload

Maximum file size: 5 MB

Choose how you would like to receive a response *

Email address or phone number associated with your Agency Healthspan account, if different from the information above.

Acknowledgment *

I understand that Agency Healthspan may need to verify my identity before processing this request.