Individual Rights Request Form

Name*

First NameLast Name
Company Name
Job Title
Email*
Phone Number
Please enter a valid phone number.
State*
State (Old Text)*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For Authorized Agents submitting a request on behalf of a consumer

Please enter information about the consumer you are representing
Consumer Name*

First NameLast Name
Consumer Email*
Consumer State*
Written Authorization Upload*

If you’re an Authorized Agent submitting a request on behalf of a consumer, you must attach written authorization from the consumer indicating you’ve been authorized to submit a request on the consumer’s behalf. The form must be signed by both you and the consumer. All forms not signed will be rejected.
Cancelof
Right to Correction – Updated Information

Please enter the information you would like us to update our records with
Updated Name

First NameLast Name
Updated Email
Updated Phone Number
Please enter a valid phone number.
Updated Date of Birth

MonthDayYear
Updated Sex Listed on Insurance
Note that you also have the right to appeal in the event that we decline to take action on a request to exercise one of your rights set forth above.

By submitting this request, I am confirming the following:
1. Accuracy: The information I have provided is true and accurate;
2. Privacy: I understand the information will be processed by Grow Therapy in accordance with our Privacy Notice;
3. Contact: Grow Therapy has the right to contact me to verify my identity and to process this request.
Should be Empty:

Individual Rights Request Form

For Authorized Agents submitting a request on behalf of a consumer

Right to Correction – Updated Information