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WA My Health, My Data Rights Request Form

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Name*

First Last

Address*

Street Address City State Zip Code

Phone*

If you choose to proceed without providing an email address, we may have difficulty processing your request and we will have to communicate with you about your request via postal mail. This may cause significant delays in processing your request.

Please Select ONE*

Delete information we have about you Deletion requests only apply to information we have collected about you up until the time we process your request. We will not delete pieces of information that are needed to comply with our legal obligations, comply with record management requirements, or as otherwise permitted by law.

Additional detail that may allow us to properly understand, evaluate and respond to your request:

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Name

This field is for validation purposes and should be left unchanged.

Users with disabilities (and any other users) who wish to make a data deletion request, data portability request and/or information disclosure request can also contact us by emailing us at: emailing us at: privacy@citizensdisability.com; calling us at: (888) 757-4011; or (781) 516-7715; or sending us mail to: Citizens Disability, 1050 Winter Street, Suite 1000, Waltham, MA 02451.

Where you make a data deletion request, data portability request and/or information disclosure request through an authorized agent, we will require that you or the authorized agent provide us with a valid written authorization executed by both parties, with the validity of such document determined by us in our reasonable, good faith discretion. Please submit such documentation to us at: privacy@citizensdisability.com; or Citizens Disability, 1050 Winter Street, Suite 1000, Waltham, MA 02451.

Making a verifiable consumer request does not require you to create an account with us. However, we do consider requests made through your password protected account sufficiently verified when the request relates to personal information associated with that account.

We will only use personal information in a verifiable consumer request to verify the requestor’s identity or authority to make the request.

For additional discussion of your privacy rights, please visit our Privacy Policy.