CCPA Form

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Welcome to the California Consumer Privacy Act Request Form

If you are a California resident, you can use this form to submit a request regarding your personal information. Please complete this form and we will respond as soon as possible.

Avēsis does not sell your Personal Information for any reason. Avēsis only shares or discloses your Personal Information and/or Sensitive Information (to the extent we have it) with third-party vendors or service providers to fulfill the services for which we have contracted with them. Therefore, the options to limit the sale or sharing of Personal Information are not included in this form.

Requestor Type(Required)

Request Type(Required)

Relationship to Individual(Required)

Representative's First Name(Required)

Representative's Last Name(Required)

Representative's Email(Required)

Representative's Phone Number(Required)

Consumer Current Relationship with Avesis(Required)

Consumer First Name(Required)

Consumer Last Name(Required)

Consumer Address 1(Required)

Consumer Address 2

Consumer City(Required)

Consumer State (CCPA applies to California Residents)(Required)

Consumer Zip Code(Required)

Consumer Country of Residence(Required)

Consumer Email(Required)

Consumer Phone Number(Required)

Employer Plan Sponsor Name or Name of Health Plan(Required)

Member ID Number(Required)

Date of Birth(Required)

Additional Information

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