Request for Access to Personal Records form

REQUEST FOR ACCESS TO PERSONAL INFORMATION

Full Name

Phone Number

Confirm Email

Previous / other names you may be known by to help with our searches and identity verification

Current and past addresses to help with our searches and identity verification(Required)

How do you wish to receive the response to your subject access request?

By [hard copy] [encrypted USB] to the address indicated above By [hard copy] [encrypted USB] to the following address (See below) By email, in an encrypted form, to the email address indicated above, and with encryption password sent by (See below)

If Following Address is selected please insert below:

If By Email is selected

Insert Email Adress:

Text to (mobile number)

Telephone to (telephone number)

Email (the same or a different)

Are you the individual making the request?

Yes, I am making a request related to personal information about me. No, I am acting as an authorized agent for the consumer. I have enclosed a California Authorized Agent Designation form completed and signed by the consumer.

Please check the nature of your request:

The categories of personal information has collected, used or disclosed about you. The categories of sources of personal information collected, used and/or disclosed about you. The business or commercial purpose for collecting or selling your personal information; Access to or a copy of certain personal information collected about you. Request to correct certain personal information collected from or about you; Request to delete certain personal information collected from or about you.

Please provide a description of the scope of your request (e.g., all customer record notes or “my employment file”). This will help us locate your personal information more efficiently. Please note that under the CCPA, requests from California consumers may be limited to personal information collected in the preceding 12 months.
[INTERNAL NOTE: If you have already satisfactorily verified the identity of the requester, section 9 below may be deleted]

Identity verification. Please provide a copy of at least one of the documents listed.

Current passport Current driver's license Utility bill (gas, electric, satellite television, landline phone bill, issued within the last three months)

Please ensure that any private or financial information contained in these documents is properly redacted in the copy that you send us. Please contact us if you have any issue in obtaining copies of the aforementioned documents

Declaration

I declare the information contained in this form is complete and accurate.

Full Name

Date

Hall Ambulance serves as the 9-1-1 paramedic provider for 94% of Kern County, California’s population.

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Hall Ambulance Service, Inc.
1001 21st Street
Bakersfield, CA 93301

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Administration Phone:
661-322-8741
DIAL 9-1-1 FOR MEDICAL EMERGENCIES

2001 O Street Bakersfield, California

(661) 322-8741

REQUEST FOR ACCESS TO PERSONAL INFORMATION

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Contact Us