Personal Information Request Form

Under certain state privacy laws (“State Privacy Law(s)”), consumers may have certain rights regarding their personal information, which are summarized in our Privacy Notice. If you are subject to such laws, or are submitting this request on behalf of an individual who is subject to such laws, you can exercise your rights by using this web form to submit your request to us. You can also exercise your rights by calling us, toll-free, at telephone: 888.849.7840 or by submitting an email containing to Privacy@PrimeTherapeutics.com containing the information required below.

We will need information requested in this form so we can verify and process your request. We will acknowledge receipt of this request immediately upon successful submission. The receipt will serve as our 10-day acknowledgement. We will respond to a complete and verifiable webform request within 45 days. We may extend that period by an additional 45 days, however, provided we notify you of the reason for the extension in writing. We may contact you to request additional information in connection with your request. Please note that the vast majority of personal information we process relates to current or former members of Prime, or health plans, employer group, and administrative service organizations that use Prime for prescription benefit management services. Such personal information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which qualifies as an exemption under all State Privacy Laws and will not be in scope for a personal information request.

Personal information relating to prescription benefits management is excluded from State Privacy Laws. The information Prime receives from members or participants in these programs includes health and medical information covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Therefore, Prime is unable to proceed with your data request to the extent it is requesting such information.

This form will not be submitted. Prime is unable to proceed with your data request because personal information relating to prescription benefits management is excluded from State Privacy Laws.

Personal information relating to prescription benefits management is excluded from CCPA. The information Prime receives from members or participants in these programs includes health and medical information is covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Therefore, Prime is unable to proceed with your data request to the extent it is requesting such information.

Personal information relating to the employment of a current/former employee, contractor, or job applicant residing in a certain state(s) may be protected.

This form will not be submitted. For more information, please visit Prime’s Human Resources page

Are you the Consumer?

Are you an authorized agent of the consumer or a Power of Attorney for the consumer?

POA - I have a Power of Attorney from the consumer pursuant to the applicable State Privacy Law. I must submit the executed POA to Prime via email to Privacy@PrimeTherapeutics.com before this request can be processed. I also acknowledge this request may be declined if I fail to complete this requirement.
Agent of Consumer - I certify that I am an authorized agent of the consumer making this request and acknowledge that I must submit an executed and completed copy form located here to Prime via email to Privacy@PrimeTherapeutics.com before this request will be processed. I also acknowledge this request may be declined if I fail to complete this requirement.

Personal Information Request Form

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