Rights Request Form - Bastion HMO

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REQUEST FOR IMPLEMENTATION OF RIGHTS

Each of the rights listed below may be exercised by submitting this request at any location of the hospital in person or by proxy, as well as electronically, by e-mail to [email protected]. Please complete in block letters and tick “✔” where necessary. Fields marked with an asterisk (*) are required to process your application.

In personProxy (a copy of the power of attorney shall be enclosed)

Subject’s Data:

Name *

Date of Birth *

Day *

Month *

Year *

Address for correspondence *

City *

State *

Postal Code

Telephone *

E-mail *

Identification *NINBVNINT'L-PASSPORTDRIVER’S LICENSEOTHERS

With regard to:

Right of accessRight to rectificationRight to erasure (‘right to be forgotten’)Right to restriction of processingRight to objectRight to automated decision makingRight to withdraw consent

Description of the requestPlease describe your request. In order to help you even more, we would like to know the reasons for it

Preferred way for feedback on the request

In writing to the correspondence addressIn Writing at hospital BranchOther

Date *

Day *

Month *

Year *

Type your full name to sign: *By typing your name above, you agree to our terms and privacy policy.

Kindly note that your request will be addressed within 30 days, as stipulated by applicable law.

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