Your Data Rights

Submit a privacy request — patients, staff, and visitors

What this form is for. Use this form to exercise your rights under HIPAA (if you are a patient), the California Consumer Privacy Act (CCPA/CPRA), or as a best-practice extension if you are an EU resident. We will respond within the time frames required by the applicable law (typically 30–45 days).

Choose your request type

Right to know / Access my data What categories and specific pieces of personal information do you have about me? Where did it come from? Who have you shared it with? Delete my data Remove personal information about me, subject to retention required by law (e.g., HIPAA audit retention). Correct my data Fix inaccurate or incomplete personal information. Portability / Data export Receive a copy of my data in a machine-readable format. Opt out of sale / sharing For your reference: we do not sell or share personal information for behavioral advertising. Submit this if you'd like written confirmation. Restrict disclosure (HIPAA) Limit how my PHI is used or disclosed (e.g., a request not to share with a specific person or insurer). Accounting of disclosures (HIPAA) A list of disclosures of my PHI in the past 6 years, excluding routine treatment/payment/operations. Other privacy question or concern Ask anything else about how we handle your data, or report a privacy concern.

Your information

We need this to verify your identity before responding. We do not use it for any other purpose.

Full name * Email address *

We will use this to contact you about your request. Use an email address you can actively monitor.

Phone (optional) Your relationship to Apple Specialty Pharmacy *

If you are an authorized agent, please describe in the message box and we will send a separate authorization form.

Date of birth (for patient verification, optional otherwise)

Only needed to verify your identity as a patient. Skip if you are a staff member, visitor, or non-patient.

Details of your request *

0 / 2000 characters

I confirm that the information above is accurate and that I am authorized to make this request. I understand Apple Specialty Pharmacy may request additional verification before fulfilling my request, and that knowingly providing false information may be a criminal offense.

✓ Request received

Thank you. Your request has been logged for review by our Privacy Officer.

Your reference number:

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We will respond by email within the time required by the applicable law (typically 30–45 days). If we cannot verify your identity from the information you provided, we will contact you for additional verification.

Save this reference number for your records.

For patients seeking medical records. If you need a copy of your prescription, medication, or care records for medical or insurance purposes, you can also call us directly. The form above is the formal HIPAA right-to-access pathway and will be answered in writing, but a phone call is often faster for routine records pickup.