Data Subject Access Request Form

Including all versions (i.e. Bill, Billy, William, etc)

I am submitting this request as *

I am submitting this request to: *

Please leave details regarding your action request or question

* If you chose to access certain personal information or sensitive personal information, we may follow up with you for additional information to confirm your identity. This is required to complete our verification process under the CCPA and other state privacy laws. We need to be able to match your information to our records to verify that you have made this request. This process is necessary to protect your personal information.

I confirm that: *

I am the individual named above.

Under penalty of perjury, I declare all of the above information to be true and accurate.

I understand that the deletion or restriction of my personal data is irreversible and may result in the termination of services with InfuSystem.

I understand that I will be required to validate my request by email, and I may be contacted in order to complete the request.

InfuSystem Data Subject Access Request Form