PracticeMatch California Consumer Request Form for Exercise of Rights Under California Consumer Privacy Act

Please Complete the Information Below

When you have completed the required information, submit the form by clicking "submit" at the bottom. After receiving this form, we will be in touch to verify your identity and respond.

1. Complete the following information of the person whose information is the subject of this request:

Name is required

Phone Number is required

Email is required

City and State of Residency is required

2. Request Type [check all that apply]:

Select all that apply

What Personal Information of mine is collected and/or processed?

I request access to specific pieces of my Personal Information (please describe in text box below)

I request access to these categories of my Personal Information (please describe in text box below)

Delete all of my Personal Information

Delete specific pieces of my Personal Information (describe in text box below)

General Questions on PracticeMatch California Privacy Policy or Main Privacy Policy (describe in text box below)

3. Additional Details. Please help us understand your request by providing additional details below.:

If Submitted On Behalf of A Consumer: provide via email (datarequest@practicematch.com) the Authorized Agent's name and written permission or a Power of Attorney ("POA") from the consumer this request concerns (a free copy of California's Uniform Statutory POA is found here: https://freepoaform.org/california/california-statutory-power-attorney-form/).

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