Consumer Data Request

Important Note: If you are a current or former patient of Virtua Health, this form does not apply to your Virtua Health medical records. For more information about Virtua Health’s practices with respect to your medical records, please read our Notice of Privacy Practices.

Requestor Information

First Name

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Last Name

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E-mail

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Telephone number

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Is this the same person whose records/data is to be requested?
I certify that the individual whose personal information is the subject of this request has authorized me to serve as their authorized agent and to act on their behalf for purposes of making this request.

Consumer Information

First Name

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Last Name

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Date of Birth

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Address

Please enter address

City

Please enter city

State

Please Select State

Zip Code

Please enter a valid zip code

E-mail

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Telephone number

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Please note, failure to provide sufficient information to verify your identity may result in a denial of your request

Type of Request (check all that apply):

Access to my Personal Data Deletion of my Personal Data Amendment to my Personal Data

Please select one option

What is your Connection to Virtua Health? (check all that apply) :

Current or Former Student at the Our Lady of Lourdes School of Nursing Donor or Recipient of Virtua Health Foundation outreach Enrolled or participated in a Certification Course at Virtua Health (such as the American Heart Association or EMT Education) Have a Child who attends or attended the Virtua Daycare program Other

Please select one option

If other, please describe

Please enter other descriptiion

Please Describe in Detail the Personal Data You Wish to Access, to Amend, or Have Deleted.

By electronically signing my name below and submitting this form, I confirm that the information provided on this form is accurate and I am the individual to whom the data relates or have authority to make this request on behalf of the data subject.

Digital Signature

Please digitally sign your name

Please only click the “Submit” button once. This form may take 1 to 2 minutes to process.

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