US State Privacy Law Consumer Request Form

Instructions: You may use this form to submit requests under US state privacy law regarding personal information collected by EyeMed that is subject to US state privacy law.

Please note that much of the personal information that EyeMed collects is exempt from US state privacy laws, including information that is protected under other federal and/or state health privacy laws. (For example, if you are a member of EyeMed, personal information about you is governed by HIPAA and is exempt from US state privacy laws. Please see our HIPAA Notice of Privacy Practices for information about how we handle your personal information subject to HIPAA.)

For certain requests, we may ask for additional information or documents to verify the identity of the consumer who is the subject of the request. The information provided through this form will be used only to respond to your request, including verifying identity, identifying personal information responsive to your request, and keeping records of your request.

*All fields are required unless marked optional.

Country of Residency

State of residence

Tell us who you are

Customer

Associate / Employee

Applicant

Contractor

Vendor

Is this request for you or someone else?

*Yes, I am making a request related to personal information about me

*No, I am acting as an authorized agent for the consumer. I understand that the request cannot be processed without EyeMed receiving written permission from the consumer demonstrating that I have been authorized to act on behalf of the consumer.

Individual's Information

Your Information

Proof of Authorization

For requests submitted by an authorized agent, you must upload written, signed permission from the individual showing that the consumer has authorized the agent to make the request. EyeMed may still need to request additional information and/or contact the consumer to verify the consumer’s identity.

Specify Your Request Type

Please submit a separate request for each request type

Request to obtain specific pieces of personal information EyeMed collected about the consumer
Request to know categories of personal information EyeMed has collected, used, or disclosed about the consumer.
Request to delete personal information EyeMed has collected from the consumer
Correct my personal information

Provider Information

Please submit your provider/doctor information if possible

Yes

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BY CHECKING THE BOX AND CLICKING “SUBMIT,” I HEREBY CERTIFY THAT THE INFORMATION ENTERED INTO THIS FORM IS COMPLETE, ACCURATE, AND UP-TO-DATE, AND THAT I AM THE CONSUMER WHO IS THE SUBJECT OF THE REQUEST, OR HAVE BEEN AUTHORIZED BY THAT CONSUMER TO ACT ON HIS/HER BEHALF, AS INDICATED ABOVE. I UNDERSTAND THAT IT MAY BE NECESSARY FOR EYEMED TO VERIFY THE IDENTITY OF THE CONSUMER AND/OR AUTHORIZED AGENT FOR THIS REQUEST, AND ADDITIONAL INFORMATION MAY BE REQUESTED FOR THIS PURPOSE.