Data Subject Access Request Form

Application

HMIS

What is your full name?

What is the email address you use to access the above app?

I am submitting this information on behalf of:

Myself

Someone else

What is the reason of your request?

Get a copy of my personal information

Edit or correct my personal information

Restrict the processing of my personal information

Delete all my personal information

I confirm the following:

Under penalty of perjury, I declare all the above information to be true and accurate.

I am the consumer of the above app or the agent authorized by the consumer to make this request on their behalf.

I understand that the deletion or restriction of my personal information is irreversible and may result in the termination of services with the above app.

I have read and agree to the privacy policy and I understand that I will be required to validate my request by email and I may be contacted in order to complete the request.

You’re not a bot, are you?

Data subject access request form