BASS Medical Group Consumer Rights Request Form

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First Name*Middle NameLast Name*

Select all that apply:

Request for disclosure (tell me about my data)Request for correction (correct my data)Request for access (give me my data)Request for deletion (delete my data)

If you are an authorized agent and are making this request on behalf of a principal, you will be required to provide a copy of the principal’s written authorization (for example a power of attorney) showing that you have been granted the authority to submit a consumer rights request on behalf of the principal. You will be contacted at either the email address or mailing address you provide below, in order to request a copy of this document for verification purposes. To the extent that the written authorization provided to us is insufficient, we will contact you for further verification at the contact information you provide below. We may additionally contact the principal in order to verify his or her identity, and to confirm your authority to make a consumer rights request on his or her behalf, prior to responding directly to you.

Additional information needed to verify your identity for request processing

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Today's Date (MM/DD/YY)Address 1*Address 2State / Province*Postal Code*Contact Number (if known)Description Amount of Recent Purchase (if known)Date of Recent Purchase (if known)Contact Phone*Contact Email*

Please indicate how you would like to receive the information requested above by checking one of the following boxes.

By Mail (at Address above)By Email (at Email above)

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