California Resident Consumer Request Form

1. This form only applies to California residents. Do you currently reside in California?

This form only applies to California residents.

California Consumer Privacy Act (CCPA)

Types of Requests and Definitions

Request to Know: A request for information about the categories of personal information we have collected about you, the categories of sources from which we collected the personal information, the purposes for collecting the personal information, the categories of third parties with whom we have disclosed your personal information, and the purpose for which we disclosed your personal information.
Request to Access: This is a request to obtain a copy of the specific pieces of personal information we have collected about you.
Request to Delete: A request that we delete your personal information that we have collected from you.

Verification Process

This is a process to determine that the consumer making the request is the consumer about whom we have collected the personal information. In order to verify your identity we will, whenever feasible, match the identifying information you provide to the personal information we already maintain. To do this we require the following information from you:

Request to Know Categories of Personal Information Collected: Provide your name, email address, phone number and home address below.
Request to Access: Provide your name, email address, phone number and home address below. Also submit a signed Declaration Form under penalty of perjury verifying your identity.
Request to Delete: Provide your name, email address, phone number and home address below. Also submit a signed Declaration Form under penalty of perjury verifying your identity.

Required fields are marked with an asterisk *.

Authorized Agents

If you are acting as an authorized agent for a consumer, we will request written authorization from the consumer or we will accept a legal Power of Attorney under the California Probate Code.

2. Please indicate here if you are acting as an authorized agent: *This question is required.

2. Do you have Power of Attorney? *This question is required.

If yes, email a copy to PersonalInformationRequest@healthtrustpg.com. No additional information is required. Please fill in N/A in the fields below.

2. First Name: *This question is required.

2. Last Name: *This question is required.

2. Email Address: *This question is required.

2. Phone Number: *This question is required.

2. Address: *This question is required.

2. City: *This question is required.

2. State: *This question is required.

2. Zip: *This question is required.

California Consumer Requests

Provide the following information as required above under "Verification Process"

2. First Name: *This question is required.

2. Last Name: *This question is required.

2. Email Address: *This question is required.

2. Address: *This question is required.

2. City: *This question is required.

2. State: *This question is required.

2. Zip Code: *This question is required.

2. Please indicate which request(s) you would like to make according to the definitions above: *This question is required.

Request to Know Categories of Personal Information Collected
Request to Access
Request to Delete

Additional Information

We will respond to requests to delete and requests to know within 45 days, unless we need more time in which case we will notify you and may take up to 90 days total to respond to your request.

If you make a Request to Delete, we will not delete personal information on archived or backup systems until the archived or backup system is next accessed or used. We will maintain records of requests that are made that include the date of request, nature of request, manner in which the request was made, the date of our response, the nature of our response, and the basis for any denial of the request if it is denied in whole or in part.

If this is a Request to Access or Request to Delete please fill out the following Declaration of Consumer. IF NOT, FILL OUT N/A.

Declaration of Consumer

2. Full name of Consumer: *This question is required.

a resident of California, in connection with my request to access personal information collected about me or to delete personal information collected from me for the past 12 months (the “Request”) by HCA Healthcare, Inc., do hereby declare, under penalty of perjury under the laws of California and the United States, that I am the consumer whose personal information is the subject of the Request.

This Declaration is made as of this date: *This question is required.

2. Consumer Signature: *This question is required.

The parties agree that this form is an agreement that may be signed electronically. By clicking on the “Submit” box below, this action confirms the parties’ consent to the use of electronic signatures and such action shall be treated the same as a traditional handwritten signature.

Before you submit, print for your records: