Individual Rights Request Form

In compliance with applicable U.S. privacy laws, and depending on your place of residence, you may have certain rights regarding your personal information. To exercise these rights, please complete and submit this form. For more details about your data rights, refer to our Privacy Notice.

If we are unable to verify your request with the information provided, we may need additional details to process your request. Rest assured, any personal information shared in connection with this request will be used solely to address your inquiry.

Important: Please do not use this form to request medical records.

Please identify your relationship with AB Holistic Health: *

Select the consumer right you would like to exercise: *

Right to Access / Portability: Right to obtain access to the personal information we have collected about you and, where required by law, the right to obtain a copy of the personal information.
Right to Know: Right to know the categories of personal information we have collected about you in the past 12 months.
Right to Correction: Right to request that any inaccuracies in your personal information be corrected, taking into account the nature of the personal information and the purposes of the processing of your personal information.
Right to Withdraw Consent / Restriction: Right to withdraw your consent or limit the purposes for which we process your information.
Right to Deletion: Right to request the deletion of personal information we have collected from you, subject to certain exceptions.
Right to Opt Out of “Sales”: Right to opt out of the “selling” or “sharing” your personal information with third parties for monetary or other valuable consideration.

Please Layout relationship

Name *

First

Last

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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:

Accuracy: The information I have provided is true and accurate;
Privacy: I understand the information will be processed by Tranador Corporation dba Applied Behavioral Holistic Health in accordance with our Privacy Notice;
Contact: Applied Behavioral Holistic Health has the right to contact me to verify my identity and to process this request.

Individual Rights Request Form

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