Privacy Rights Request Form

We respect your privacy and provide this form to help you exercise your legal data rights under applicable state privacy laws.

State data privacy laws provide consumers with specific rights regarding their personal information. In accordance with legal guidelines, LeafyRX never asks for a government ID photo, Social Security Number, or sensitive credentials to process your request.

Please fix the following before submitting:

1. Select Request Type(s)

Select all options that apply to your request:

Know / Access My Personal Information Request a copy of the specific pieces and categories of personal information we have collected about you.

Delete My Personal Information Request that we delete personal information collected from you, subject to legal exceptions.

Correct Inaccurate Information Request correction of inaccurate personal information that we maintain about you. (Requires explanation in the details field below)

Opt Out of Sale / Sharing (Targeted Advertising) Direct us not to sell or share your personal information for cross-context behavioral advertising. (Processed immediately without verification)

Limit Use of Sensitive Personal Information Direct us to limit the use and disclosure of your sensitive personal information to strictly necessary service purposes.

Appeal a Prior Decision Submit an appeal regarding a previous privacy request determination. (Requires original request ID and details below)

Important Notice regarding Deletion: Requesting deletion permanently removes your personal information and records across our systems, subject to legal and regulatory retention obligations. To safeguard your data against unauthorized deletion, you will receive an identity verification email that must be confirmed within 72 hours.

Immediate Opt-Out Processing: Direct requests to opt out of the sale or sharing of personal data do not require identity verification and will be applied directly across our systems upon submission.

2. Submitting As

Myself

I am making this request for myself

Authorized Agent

I am authorized to act on behalf of the consumer

3. Consumer Information

First Name

Last Name

Email Address

Please use the email address associated with your LeafyRX account.

State of Residence

Phone Number (Optional)

Order or Account Reference (Optional)

Helps our records team locate your profile more quickly without requesting further details.

Request Details * (Required for Correct & Appeal) (Optional)

Specific information required: Please describe which records are inaccurate and specify the updated information, or provide the reference ID of the determination you are appealing.

Authorized Agent Information

Under state regulations, authorized agents must provide valid documentation demonstrating legal authority to act on behalf of the consumer (e.g. written authorization signed by the consumer or a valid Power of Attorney).

Agent Full Name

Organization / Agency (Optional)

Agent Email Address

Agent Phone Number (Optional)

Signed Authorization Document Choose file or drag & drop PDF, JPG, or PNG document. Max size: 10 MB.

Document ready for upload

Authorized Agent Documentation

Legal Attestation: I am the consumer named above or authorized to act on their behalf, and this information is accurate.

Alternative Submission Methods

You may also exercise your data privacy rights by emailing our Privacy Team at [email protected] or by calling our privacy intake line at (405) 867-6926 .

Submissions are encrypted in transit and handled strictly per CCPA/CPPA guidelines.

Privacy Rights Request Form

Request Submitted Successfully

What happens next:

3. Consumer Information

Alternative Submission Methods