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Privacy Rights Request Form

In order to submit a privacy request, please select the type of request you would like to make and fill out any required fields below to help us identify you. Please note that in order to keep your data secure, if you are unable to provide information sufficient to identify yourself and verify your request, the request may not be completed, and you will be notified of that determination.

Patient Status(Required)

The personal information that we may have collected about patients is protected health information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA). Because we already protect PHI as required by HIPAA, that PHI is exempt from coverage under state-specific consumer privacy laws. Our Notice of Privacy Practices describes how we use and disclose PHI and rights with respect to PHI. For more information about our management of PHI, please visit our Notice of Privacy Practices, available at: Notice of Privacy Practices

Please indicate whether this request relates to information about you (or the individual you are submitting this request on behalf of) as a patient of CareMed:

YES – This request relates to information about me as a patient of CareMed (or, if submitting on behalf of another person, this request relates to information about the person for whom I am submitting this request as a patient of CareMed.)

NO – This request does NOT relate to information about me as a patient of CareMed (or, if submitting on behalf of another person, this request does NOT relate to information about the person for whom I am submitting this request as a patient of CareMed.)

Based on the definitions of "Yes" and "No" above, please make your selection accordingly.

STATE – FOR CALIFORNIA, COLORADO, CONNECTICUT, OR VIRGINIA RESIDENTS ONLY.(Required)

Please do not submit this form unless you are a resident of California, Colorado, Connecticut, or Virginia. For more information about your data rights, please visit our Privacy Policy

Relationship to CareMed(Required)

I, or the individual I am submitting this request on behalf of, am/is a/an:

Request Type(Required)

Please select the applicable request type you would like to submit:

Consumer Contact Information(Required)

Name

Name at Time of Service (If Different)

Street Address(Required)

Email Address(Required)

Telephone Number(Required)

Authorized Agents(Required)

I am an Authorized Agent (only select “YES” if you are submitting this for someone else). An “Authorized Agent” is a natural person (or, under the California Consumer Privacy Act, as amended, a business entity registered with the Secretary of State) that an individual has authorized to act on their behalf subject to requirements set forth in the applicable data protection law. A member of our team will contact you to provide proof of authorization to act on the individual’s behalf.

If you have selected “YES” above to indicate that you are an Authorized Agent, please provide the information below:

Authorized Agent Name(Required)

Authorized Agent Email Address(Required)

Authorized Agent Telephone Number(Required)

Upload Proof of Authorization

Drop files here or

Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 50 MB.

Parents or Guardians(Required)

I am a parent or legal guardian (only select “YES” if you are submitting this request on behalf of a minor child for whom you are the parent or guardian). A member of our team will contact you to verify that you are the parent or guardian of the child identified.

Parent or Guardian Name(Required)

If you have selected “YES” to indicate that you are the parent or guardian of the minor child identified, please provide the information below:

Parent or Guardian Email Address(Required)

Parent or Guardian Telephone Number(Required)

Consent(Required)

By submitting this webform, you confirm that the information provided is true and accurate. You acknowledge that the information submitted is being used by CareMed for purposes of verification, and retained for purpose of record-keeping and audits.

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