Washington Consumer Health Data Request

Request type *

Confirm whether Astoria collects, shares, or sells my Washington consumer health dataAccess my Washington consumer health dataRequest deletion of my Washington consumer health dataWithdraw consent for future collectionWithdraw consent for future sharingRequest list of third parties/affiliates with whom my consumer health data was shared or soldAppeal a prior decisionOther

Consumer first name *

Consumer last name *

Email address used on form or inquiry *

Phone number used on form or inquiry

Mailing address

Street address *

City *

State *

ZIP code *

Are you a Washington resident or did you submit a request from Washington? *

Website or brand used *

Approximate date of inquiry

Type of inquiry *

Preferred response method *

Additional information to help locate records

Include any details that may help us locate your inquiry or records.

Lead ID

Optional, if known.

Call ID

Optional, if known.

TrustedForm certificate ID

Optional, if known.

Jornaya / LeadiD

Optional, if known.

Campaign / source

Optional, if known.

Authorized agent? *

I am the consumerI am an authorized agent submitting on behalf of the consumer

Signature

Typed name (electronic signature) *

Date *

Consumer verification certification *I certify under penalty of perjury that I am the consumer identified in this request or am authorized to submit this request on the consumer's behalf, and that the information provided is true and accurate.

Verification *

You do not need an account to submit this request.