Privacy Form

If you are a California resident, or are acting on another California resident’s behalf, you may complete this form to submit a verified written request. MDVIP will acknowledge the request within ten (10) days.

For more information about our Privacy Practices at MDVIP, please visit https://www.mdvip.com/privacy-policy/.

I am submitting this request on behalf of

Myself - We may request that you submit a signed declaration, under penalty of perjury, confirming that you are the actual consumer whose personal information is the subject of the request.

Another California Resident - Data requests made on behalf of another California resident may require submission of additional proof that you can act on the other California resident’s behalf, such as providing MDVIP a Power of Attorney.

First Name*

Last Name*

California Address 1*

California Address 2

California City*

State*

California Zip Code*

Phone Number*

Email Address*

Request Details*

I verify that I am a California resident or that I am legally authorized to submit this request on behalf of another California resident, and that the information contained herein is accurate.

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