Consumer Data Request Requestor InformationName(Required) First Last Email(Required) Telephone number(Required)(Required) 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 InformationName(Required) First Last Address(Required) Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Telephone number(Required)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)(Required) Access to my personal data Deletion of my personal data Amendment to my personal data What is your connection to Cooper University Health Care? (check all that apply):(Required) Cooper Foundation donor or mailing list. Subscribed to newsletters on or downloaded e-book from the Cooper website. Taken classes or participated in support groups at Cooper. Signed up for an event at Cooper. Provided comments on Cooper social media posts or messaged Cooper through social media. Left a review on a Cooper provider or location on a third-party website. Sent Cooper a message using the “Contact Us” form on the Cooper website. Other If other, please describe(Required) Please Describe in Detail the Personal Data You Wish to Access, to Amend, or Have Deleted.(Required)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 (enter full name)(Required)
