Medbridge Data Use Request Form

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Please submit the following information, including your e-mail, name, access code, and your clinician or healthcare provider for our team to validate your identity and promptly process your data use request.

It may take up to 30 business days for Medbridge to fully process your data request.

Email *

Name *

Access Code *

Your access code is an eight digit code generated by your treating clinician to access your Medbridge account. If you do not have an access code or remember your access code, please put N/A.

Healthcare Provider *

Providing the clinician or healthcare provider affiliated with your account can assist our team in quickly processing your data request. If you do not remember your clinician or provider, please put N/A.

Type of Request *

Please select one or more of the following data use requests below.

Delete my Medbridge account and associated data

Know the categories and sources of personal information collected by Medbridge and the third parties with which Medbridge shares information to provide my account services

Request a log of my Medbridge account data and associated account activity

Opt out from the sale / sharing of my Medbridge data with third parties

Required

Other Details

Please provide any further details about your request.

A copy of your responses will be emailed to the address you provided.

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