Data Access Request

* The red asterisk indicates the field is required.

Requestor's Full Name

Requestor's Mailing Address

Requestor's Telephone Number

Requestor's Email Address

Which Consumer Rights Law are you invoking?

(ex. CCPA/CPRA, VCDPA, GDPR, etc.)

Are you the consumer/data subject?

Yes, I am making a request related to personal information about me.

No, I am acting as an authorized agent for the consumer (California Residents Only).*

No, I am a child's parent/legal guardian requesting data on behalf of my minor child. Please provide documentation.

*You must make the CA authorized agent designation form available upon request. To use an authorized agent, you must provide the agent with written authorization. To the extent we are unable to verify the identity of the person submitting this form, we may request additional information from the person making the submission.

Consumer's Full Name

Consumer's State/Province of Residence

Consumer's Country of Residence

Consumer's Email Address

What has been the consumer's affiliation to MEDITECH?

Examples: "I was a job applicant", "I attended an event", "I was an employee of MEDITECH", "I am a MEDITECH customer"

Name of Your Primary Contact at MEDITECH, if any

Request Type** (check all that apply)

Request to know categories of personal information MEDITECH has collected, used and/or disclosed about the consumer.

Request to obtain specific pieces of personal information MEDITECH collected about the consumer.

Request to delete personal information MEDITECH has collected about the consumer.

Request to correct inaccuracies in the consumer's personal data.

If checked, please add more detail below.

If request to correct inaccuracies, please specify the data to be corrected.

Request to Limit Use of Sensitive Data

If checked, please add more detail below.

If requesting to limit use of sensitive data, please specify what data categories of sensitive data you want to limit the use of.

Opt out of the processing of the personal data for purposes of.

If checked, please add more detail below.

If opting out of the processing of the personal data, for which purposes is this being requested.

Targeted Advertising

Sale of personal data (MEDITECH does not sell your data)

Profiling in furtherance of decisions that produce legal or similarly significant effects concerning the consumer.

**If your request applies to online activity information that MEDITECH may have collected through cookies or similar technologies, you must make your request from the browser or device that you have previously used to access MEDITECH’s websites or apps. This allows us to read any identifier that we have assigned to your browser or device.

By submitting this form, I hereby certify that the information entered into this form is complete, accurate, and up-to-date, and that I am the consumer who is the subject of the request or have been authorized by that consumer to act on his/her behalf, as indicated above. I understand that it may be necessary for MEDITECH to verify the identity of the consumer and/or authorized agent for this request, and additional information may be requested for this purpose. I also may be asked to provide further clarifying information regarding the information or action I am requesting from MEDITECH.

MEDITECH reserves the right to refuse requests, in part or in whole, to the extent permitted by law, if we are unable to verify your identity, or if we cannot verify your authority to act on behalf of another person.

Please note that if the information you request reveals details directly or indirectly about another person, it may be excluded from any data access response sent to you.

I understand and accept