state-privacy-new-disclaimers

(* required)

First Name:

Last Name:

Email Address:

Street Address 1:

Street Address 2:

City:

ZIP:

DOB:

If Other, please specify:

If Other, please specify:*

Request Details:

Request access to my Personal Information (information about the categories of personal information collected)

Request deletion of my Personal Information

Request correction of my Personal Information

Request a copy of my Personal Information (a data portability request)

Do not share or sell my Personal Information

Alleged discrimination based on prior right request

Other

Request Details:

If Other, please specify

${email_field} - Automation Tool Email (To be hidden)

*Failure to list the business or services related to your request will result in a denial.
For requests related to UnitedHealthcare, please contact the number on the back of your health plan ID card.
For requests related to employees and applicants, please contact us at 1-800-561-0861 and let us know you are calling about a “CPRA Request.”