Berry Street Data Subject Rights Request Form

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If you would like to be removed from our promotional communications, click on the “unsubscribe” button located at the bottom of Berry Street promotional email communications or reply “STOP” to any promotional texts we may send.

Some states in the U.S. have implemented comprehensive privacy laws that provide residents of those states with certain data subject rights. If your state appears in the list when you click the “Please indicate the U.S. state in which you reside” box below, then your state has passed such a law. If it does not appear, then your state laws do not include these rights at this time.

To submit a request to exercise a data subject right, please select and enter the required fields on the form below. We require this information to process your data subject rights request, and to take steps to verify your identity.

Please indicate where you reside: *

California

Colorado

Connecticut

Montana

Nevada

Oregon

Texas

Utah

Virginia

Washington

Please indicate how you interact with us: *

Consumer/Account Holder/Patient

Healthcare/Other Professional

Employee/Former Employee

Job Applicant

Vendor/Contractor

Type of Request *

Request to Confirm/Know/Access/Obtain Personal Information

Request to Delete/Erasure of Personal Information

Request to Correct/Rectify Personal Information

Request to Opt-Out of Selling or Sharing Personal Information for Targeted Advertising Purposes

Request to Limit Use of My Sensitive Personal Information

Request to Appeal a Denial of a Prior Request

Right to Withdraw Prior Consent

Other:

Are you acting: *

On your own behalf

As an authorized agent (Please note: We will contact you by phone upon our receipt of your request.)

First name *

Last name *

Email *

Address *

City *

Zip or Postal Code *

Phone number *

By submitting this request, I confirm the following:

(1) Accuracy: I declare under penalty of perjury under the laws of the state in which I reside, that the above information is true and correct and that I am authorized to make this request. (2) Service

Clear selection

By submitting this request, I confirm the following:

(1) Accuracy: I declare under penalty of perjury under the laws of the state in which I reside, that the above
information is true and correct and that I am authorized to make this request.
(2) Service Provider Role: I understand Berry Street may engage a service provider to receive, triage, manage, and document receipt of and
responsive action taken pursuant to your request.
(3) Contact: Berry Street has the right to contact me to verify my
identity and to process this request.

Click below to confirm the above statement before submitting. *

I confirm.

Submit

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