Privacy Form

Depending on where you reside, you may have certain rights regarding your personal information. To exercise these rights, please fill out this form. For more information about our privacy practices and other choices available to you, please see our Privacy Policy.

Access: request to know more about and access your personal information.

Delete: request deletion of your personal information. We may retain certain information as required or permitted by law. Please note that deletion of your information may include your membership and benefits, online accounts, and may impact other services and experiences you receive from us.

Correction: request correction of inaccurate personal information. Please provide additional information in the “Request Details” field concerning what information you believe is inaccurate and should be corrected.

To exercise your choices with respect to cookies and similar technologies (use of which may also constitute “sales,” “sharing,” or “targeted advertising,” under certain privacy laws), please click the Your Privacy Choices

link in the footer of our website and follow the instructions shown.

First Name

Last Name

State

Select Request Type - *Option only available to residents of the following states: California, Colorado, Delaware, Indiana, Maryland, Nebraska, New Jersey, Texas, or Virginia

Request Type

Zip Code

Note:

The above fields concerning the consumer will be used to search our systems for information that corresponds to this request. We recommend that you print a copy of this submission for your records.

Acknowledgment

By submitting this request, I am confirming the following: (1) Accuracy: the information I have provided is true and accurate; and (2) I understand the information will be handled by MDVIP, LLC in accordance with its Privacy Policy.