Data Subject Request Concerning Personal Information - ISYS Case Management Solutions, Inc

Please use this form to submit requests to access, correct, or delete your personal information; to opt-out of the sale of your personal information or disclosure of that information for targeted advertising; or to limit the use or disclosure of your sensitive personal information. We may ask you for additional information to verify your identity and/or authority to make this request. If we ask for proof of identity, please send any sensitive information by secure means.

We will endeavor to respond to your request promptly. In general, we will respond within 45 calendar days from the date we receive your request. If we need additional time, however, we will let you know within the first 45 calendar days following the date we receive your request. Please note that certain conditions may limit our ability to comply with your request and, under certain limited circumstances, we may charge a reasonable fee for responding to your request.

To submit your request, please complete this form and click “SUBMIT” below. If you are submitting the form by email, please email it to [email protected]. If we need additional information to process your request, we will generally notify you using the mechanism you designate below. However, we may instead respond by email or regular mail, where applicable. We will use any information we collect for verification purposes solely for that purpose.

If you have any questions, please contact us at (800) 992-8100 or [email protected]

If you are the data subject or are submitting a request on behalf of the data subject, please provide the following information about the data subject.

Data Subject’s Full Name:*

Data Subject’s Date of Birth:

Data Subject’s Home Address:*

Data Subject’s Mobile Phone Number:

Data Subject’s Home Phone Number:

Data Subject’s Email Address:

Data Subject’s Relationship to Us:

Other - Please Specify:

If you are submitting a request on behalf of a data subject, please provide the following information about your authority, as the requesting party, to make the request. You will also need to provide the data subject’s written authorization or appropriate legal authorization to act on the data subject’s behalf which you may upload to this form.

Requesting Party’s Full Name:

Requesting Party’s Mobile Phone Number:

Requesting Party’s Relationship to Data Subject:

Form of Authorization:

Authorization Attached:

Yes
No

If authorization attachment is clicked yes, you will need to sign and email this document. A copy of this document and email instructions will be sent to the email you submitted in this form.

Please select the request type(s) below.

Right to Know/Obtain Indicate whether you would like information on some or all the following:

Categories of data subject’s personal information collected by the Company.
Categories of sources from which the data subject’s personal information is collected by the Company.
The Company’s business or commercial purpose for collecting the data subject’s personal information, selling it, or disclosing it for targeted advertising.
Categories of third parties to whom the Company discloses the data subject’s personal information.
Copies of the specific pieces of the data subject’s personal information collected by the Company.
All of the above.

Specify which pieces (e.g., email address, mobile phone number, government issued identification number, etc.):

Right to Correct
Describe the personal information you would like corrected and include the corrected version.

Contact Information:

Billing Information:

Online Account Information:

Financial Account Information:

Other:

Delete Personal Information

Describe the personal information you would like deleted:

Specific elements of the data subject’s personal information (e.g., email address, mobile phone number, government issued identification number). Please list:
Specific categories of the data subject’s personal information (e.g., all personal information collected prior to a specific date, search history). Please list:
All of the data subject’s personal information.

Specify which pieces (e.g., email address, mobile phone number, government issued identification number, etc.):

Opt-Out of Sale of Personal Information or Disclosure for Targeted Advertising

Indicate whether you would like to opt-out of the sale of your personal information or disclosure for targeted advertising:

Yes, I would like to opt-out of the sale of my personal information or disclosure of it for targeted advertising.
No, I do not wish to opt-out.

Limit Use or Disclosure of Sensitive Personal Information

Yes, I would like to limit the use or disclosure of my SPI.
No, I do not wish to limit the use or disclosure of my SPI.

If you are requesting limitations on the use or disclosure of your SPI, please identify the SPI data elements that are subject to your request:

Please identify the format in which you would like us to respond to your request:

Using my existing online account, if applicable.
By email to:
In writing to the following address:

Enter address of where you would like your response.

By submitting this request, I certify that the information provided is correct and that I am authorized to make this request.*

Yes

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