Privacy Rights Request Form

PRIVACY RIGHTS REQUEST FORM AND
REQUEST TO NOT SELL OR SHARE PERSONAL INFORMATION

Depending on the Personal Information that CMD has about you, and depending on the manner in which we process your Personal Information, you may have the following privacy rights related to our processing of your Personal Information. Please note that these rights do not apply with respect to your PHI that we process. The rights that you have with respect to your PHI are more fully described in our HIPAA Notice of Privacy Practices.

Be informed about how your Personal Information is being processed, the categories of Personal Information being processed, and the categories of sources from which your Personal Information has been collected;
Be informed about whether and how your Personal Information being processed is being disclosed to unaffiliated third parties, and which categories of your Personal Information are being disclosed to unaffiliated third parties;
Access or receive a copy of your Personal Information;
Rectify, update or correct inaccurate or incomplete Personal Information about you;
Erasure or deletion of your Personal Information;
Object and opt-out of processing of your Personal Information;
Limit processing of your Personal Information;
Portability of your Personal Information in a commonly used format;
Withdrawal of your consent to processing of your Personal Information to the extent such processing is based on your consent, provided that such withdrawal will not affect the lawfulness of CMD’s use of your Personal Information before such withdrawal; and
Non-discrimination for exercising your privacy rights.

To make a request concerning these rights, please provide complete and accurate information in each of the following text boxes. Once you have done so, please click the “Submit” button at the bottom of this page.

Name(Required)

First Last

Address(Required)

Street Address State / Province / Region Country

Email(Required)

Enter Email Confirm Email

Phone(Required)

Are You Opting-Out of the Sale or Sharing of Your Personal Information?(Required)

Please Describe Each Privacy Rights Request You Are Making(Required)

CAPTCHA

We will confirm receipt of all completed Privacy Rights Request Forms within 10 days of receipt. We will substantively respond to all such requests within 30 days, subject to any lawful extension of that period. Please note that there may be a delay in processing a request while we verify that the request is valid and originates from you as opposed to an unauthorized person.

Please be aware there may be valid reasons to refuse a request, including legal and regulatory requirements that we retain and process certain information. Also, please be aware that certain requests may limit or prevent us from providing Services to you. In those situations, we will notify you in writing within 30 days. You may also contact our Data Privacy Officer for help with those situations.

CMD will not discriminate against you if you exercise any of the foregoing rights or any other rights under Privacy Laws, including, by not denying Services to you, not providing a different level or quality of Services to you, and not suggesting that you will receive a different level or quality of Services. However, certain requests may limit or prevent us from providing the Services to you.

Capitalized terms that are not defined here are defined in our Privacy Policy.

For questions or concerns, please contact our Data Privacy Officer as follows:

(603) 319-4718
DataPrivacy@convenientmd.com
360 US-1 Bypass, #102, Portsmouth, NH 03801

Last Updated: August 2024

Privacy Rights Request Form