SPR Therapeutics

SPRINT PNS System

Consumer Health Data Request Form

SPR Therapeutics (“SPR”) is committed to respecting the privacy of its consumers’ health data.  Our Consumer Health Data Policy, as well as this request form allows consumers to understand and exercise their rights and obligations under the Washington State My Health My Data Act (“MHMD Act”) and other similar state consumer health privacy laws.

Your Consumer Health Data Privacy Rights

Under the MHMD Act, as well as other similar state consumer health privacy laws, you have specific rights as set forth in our Consumer Health Data  Policy regarding your consumer health data (subject to certain exceptions).  This section explains how to exercise those rights.  SPR will never discriminate against you for exercising any of your rights.

To exercise your rights, simplify fill out the form below.  We will need to authenticate your request and process it as required by the applicable laws, generally within 45 days of us receiving your request.  You have the right to appeal if we deny your request by requesting a review of our decision.  We take your rights seriously and will judiciously consider your appeal.  But if upon further evaluation, we deny your appeal, you may contact the Washington State Attorney General to submit a complaint.

Please complete this form to exercise your rights under our Consumer Health Data Privacy Policy. Please answer all questions accurately so that we may authenticate your request and identity. All communications regarding your request will take place in our secured portal.
Your Name
Current State of Residence

Authentication Information

Please fill out your contact information, or the contact information of the individual you are submitting this request for (if submitting on behalf of another). All contact information should be consistent with information previously provided to SPR Therapeutics.
Address
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Certification

By submitting this form, under penalty of perjury, I certify that I am the individual consumer whose personal information is the subject of this request or that I am the authorized representative of the individual whose personal information is the subject of this request. The information I have provided is true, accurate, and complete, and I give my consent for SPR Therapeutics and its agents to use such information in responding to my request. I understand that I may be required to provide proof of my identity and if I am authorized agent, that I will be required to provide proof in writing of my status of the individual’s authorized agent and additional information to confirm my identity. I acknowledge and agree to the terms set forth above, inclusive of the terms in SPR Therapeutics’ Consumer Health Data and Information Privacy Policy and the MHMD Act, or any other applicable state laws. It is my intention that this electronic request to exercise a right under the MHMD Act shall carry the same force and effect as if I had manually signed this request.
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