Printable Request Form

Request Form

You may order information on yourself or someone whom you have legal authority over, such as a minor. If
you are ordering information for someone other than yourself, you will need to submit paperwork to prove you
have authorization. You can submit questions and/or documents to us via our LexisNexis Risk Solutions
Reports Help page https://consumer.risk.lexisnexis.com/help. If you need to speak to a live LexisNexis Risk
Solutions Consumer Center representative, please call 1-888-497-0011.

To submit a request, you are required to provide your First Name, Last Name, Street Address, City, Zip, and
Date of Birth. Depending on the type of request, you may also be required to provide either your Social
Security Number or Your Driver’s License Number and State. The information that you provide will only be
used by LexisNexis Risk Solutions to verify your identity and process your request. Your information will not
be given or sold to any other company. We may not be able to comply with your request if we are unable to
confirm your identity or to connect the information you submit in your request with personal information in our
possession.

Please complete all the sections on the form so that we may properly process your request. If we are unable
to process your request, we will notify you via U.S. Mail.

Personal Information: Note: *Required ⁺At least one is required.

First Name* Middle Name Last Name* Suffix (e.g., Sr.,)

Resident Address:
Street Address* City * State* Zip*
Delivery Address (Mailing Address) if Not the Same as Resident Address:
Street Address* City * State* Zip*
Email: Email is optional but must be provided and verified to include
email- linked data in your request.
LexisNexis Risk Solutions will use your personal information in compliance with our Privacy Notice, which
is available at: https://risk.lexisnexis.com/state-privacy-act-notice.

Request and Receive Your Consumer Disclosure Report

Select the Request Your Consumer Disclosure Report checkbox below to request a copy of your
information. California, Colorado, Connecticut, Utah, and Virginia residents will receive both their LexisNexis®
Risk Solutions Consumer Disclosure Report (pertaining to the Fair Credit Reporting Act) and their State
Privacy Act Report pertaining to the Data Protection Act (DPA).
Request Your Consumer Disclosure Report
Once we have verified and processed your report request, you will receive a letter via U.S. Mail.

Request a Description of Procedure Letter

Select the Request a Description of Procedure Letter checkbox below to receive a letter from LexisNexis
that is personal to your dispute request(s) and describes how we process dispute(s) that you may have in
the system.
Request a Description of Procedure Letter
Correct My Personal Information
In some circumstances, you may also exercise your right to request the correction of inaccurate personal
information maintained about you. To submit a correction request, contact us via U.S. Mail at the address
at the bottom of this document or call us at 1-888-217-1591 to speak to a live LexisNexis Risk Solutions
Consumer Center representative.

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Additional Privacy Options for California Residents

As a California resident, you have additional options under the California Privacy Laws. To request any
of the following options, please select the check boxes below.
Notice of Right to Opt-Out of Sale/Sharing: A Do Not Sell or Share My Personal Information
request, sometimes referred to as an opt-out request, will restrict your personal information that is subject
to the requirements of the California Privacy Laws from being sold to a third party and from sharing such
personal information for cross-context behavioral advertising if applicable. Our products and services are
not linked to tracking technologies utilized through our websites for cross-context behavioral advertising,
and we do not share personal information in our products and services for cross-context behavioral
advertising. A Full Opt-Out request will restrict your personal information from being sold to a third party
subject to certain exceptions. A Partial Opt-Out request will opt-out your personal information we
maintain that is subject to the California Privacy Laws except for any data we have relative to your
occupation or profession, which will continue to be sold to third parties. In any case, an opt-out request will
not apply to information that is exempt from the requirements of the California Privacy Laws. If you have
previously opted out but instead want to authorize your personal information to be sold, you may submit
an Opt-In request. For more information, or for additional methods to submit an opt-out request, see our
California Privacy Rights page at https://consumer.risk.lexisnexis.com/california.
Notice of Right to Limit the Use of My Sensitive Personal Information
A Limit the Use of My Sensitive Personal Information request will prevent your sensitive personal information
that is subject to the requirements of the California Privacy Laws from being used or disclosed, subject to certain
exceptions provided by law. A Limit Use request will limit the use and disclosure of sensitive personal
information subject to certain exceptions.
o (Full Opt-Out): Do Not Sell or Share My Personal Information
Limit Use: Limit the Use of My Sensitive Personal Information
o (Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My
Personal Information
o (Opt-In): Allow for the Sale of My Personal Information
Note: An opt-in request can be submitted to remove a California opt-out from your file in the event you
want your personal information to continue to be sold to a third party.
Delete My Personal Information Request
Additional Privacy Options for Colorado Residents
As a Colorado resident, you have additional options under the Colorado Privacy Act (CPA).
Notice of Right to Opt-Out of Sale/Sharing:
A Do Not Sell or Share My Personal Information request, sometimes referred to as an opt-out request, will
restrict your personal information that is subject to the requirements of the CPA from being processed for
purposes of (I) targeted advertising, (ii) the sale of personal data, and (iii) profiling in furtherance of
decisions that produce legal or similarly significant effects concerning you, if applicable. Our products and
services are not linked to tracking technologies utilized through our websites for targeted advertising, and
we do not sell personal information in our products and services for targeted advertising online.

A Full Opt-Out request will opt-out your personal information from being sold to a third party or used for
such profiling subject to certain exceptions.
A Partial Opt-Out request will opt-out all your personal information we maintain that is subject to the CPA
except for any data we have relative to your occupation or profession, which will continue to be sold to third
parties. In any case, an opt-out request will not apply to information that is exempt from the requirements of the
CPA. If you have previously opted out but instead want to authorize your personal information to be sold, you
may submit an Opt-In request. For more information, or for additional methods to submit an opt-out request,
see our Colorado Privacy Rights page. https://consumer.risk.lexisnexis.com/colorado

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o (Full Opt-Out): Do Not Sell or Share My Personal Information

o (Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My Personal
Information
o (Opt-In): Allow for the Sale of My Personal Information
Delete My Personal Information Request
Additional Privacy Options for Connecticut Residents
As a Connecticut resident, you have additional options under the Connecticut Data Privacy Act (CTDPA).
Notice of Right to Opt-Out of Sale/Sharing:
A Do Not Sell or Share My Personal Information request, sometimes referred to as an opt-out request, will
restrict your personal information that is subject to the requirements of the CTDPA from being processed for
purposes of (I) targeted advertising, (ii) the sale of personal data, and (iii) profiling in furtherance of
decisions that produce legal or similarly significant effects concerning you, if applicable. Our products and
services are not linked to tracking technologies utilized through our websites for targeted advertising, and
we do not sell personal information in our products and services for targeted advertising online. A Full
Opt-Out request will opt-out your personal information from being sold to a third party or used for such
profiling subject to certain exceptions. A Partial Opt-Out request will opt-out all your personal information
we maintain that is subject to the CTDPA except for any data we have relative to your occupation or
profession, which will continue to be sold to third parties. In any case, an opt-out request will not apply to
information that is exempt from the requirements of the CTDPA. If you have previously opted out but
instead want to authorize your personal information to be sold, you may submit an Opt-In request. For
more information, or for additional methods to submit an opt-out request, see our Connecticut Privacy
Rights page. https://consumer.risk.lexisnexis.com/connecticut.
o (Full Opt-Out): Do Not Sell or Share My Personal Information
o (Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My Personal
Information
o (Opt-In): Allow for the Sale of My Personal Information
Delete My Personal Information Request
Additional Privacy Options for Utah Residents
As a Utah resident, you have additional options under the Utah Consumer Privacy Act (UCPA). To request any
of the following options, please select the check boxes below.
Notice of Right to Opt-Out of Sale/Sharing:
A Do Not Sell or Share My Personal Information request, sometimes referred to as an opt-out request, will
restrict your personal information that is subject to the requirements of the UCPA from being processed for
purposes of (I) targeted advertising, and (ii) the sale of personal data, as applicable. Our products and
services are not linked to tracking technologies utilized through our websites for targeted advertising, and we
do not sell personal information in our products and services for targeted advertising online.
A Full Opt-Out request will opt-out your personal information from being sold to a third party subject to
certain exceptions. A Partial Opt-Out request will opt-out all your personal information we maintain that is
subject to the UCPA except for any data we have relative to your occupation or profession, which will
continue to be sold to third parties. In any case, an opt-out request will not apply to information that is exempt
from the requirements of the UCPA. If you have previously opted out but instead want to authorize
your personal information to be sold, you may submit an Opt-In request. For more information, or for
additional methods to submit an opt-out request, see our Utah Privacy page.
https://consumer.risk.lexisnexis.com/Utah
o (Full Opt-Out): Do Not Sell or Share My Personal Information
o (Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My Personal
Information
o (Opt-In): Allow for the Sale of My Personal Information
Delete My Personal Information Request

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Additional Privacy Options for Virginia Residents

As a Virginia resident, you have additional options under the Virginia Consumer Data Protection Act
(“VCDPA”). To request any of the following options, please select the check boxes below.
Notice of Right to Opt-Out of Sale/Sharing: A Do Not Sell or Share My Personal Information request,
sometimes referred to as an opt-out request, will restrict your personal information that is subject to the
requirements of the VCDPA from being processed for purposes of (I) targeted advertising, (ii) the sale of personal
data, and (iii) profiling in furtherance of decisions that produce legal or similarly significant effects concerning you,
if applicable. Our products and services are not linked to tracking technologies utilized through our websites for
targeted advertising, and we do not sell personal information in our products and services for targeted advertising
online.
A Full Opt-Out request will opt-out your personal information from being sold to a third party or used for such
profiling subject to certain exceptions. A Partial Opt-Out request will opt-out all your personal information we
maintain that is subject to the VCDPA except for any data we have relative to your occupation or profession, which
will continue to be sold to third parties. In any case, an opt-out request will not apply to information that is exempt
from the requirements of the VCDPA. If you have previously opted out but instead want to authorize your personal
information to be sold, you may submit an Opt-In request. For more information, or for additional methods to
submit an opt-out request, see our Virginia Privacy page at https://consumer.risk.lexisnexis.com/virginia.
o (Full Opt-Out): Do Not Sell or Share My Personal Information
o (Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My Personal
Information
o (Opt-In): Allow for the Sale of My Personal Information
Delete My Personal Information Request
Note: An opt-in request can be submitted to remove a Virginia opt-out from your file in the event you want
your personal information to continue to be sold to a third party.
Important Message Regarding Your Professional Information
As a California, Colorado, Connecticut, Utah, or Virginia resident, in some circumstances you may be able to
request to opt-out of your personal information being sold to third parties, which may include some
professional information. However, please be advised that opting out of the sale of your professional
information may result in the following:
• Incorrect or incomplete information in directories for patients and members when searching for you and
your practice.
• Delayed prescription fills and/or denial of prescriptions for your patients at point of dispensing; and/or:
• Decreased ability for you and your practice to be identified for referrals.
Important Message Regarding Your Personal Information
As a California, Colorado, Connecticut, Utah, or Virginia resident, when you visit our websites we sometimes
use tracking technologies which may be considered a “sale” of your personal information for targeted advertising.
You may request to opt-out of such tracking technologies by utilizing the “Cookie Settings” link on our websites
that use tracking technologies for targeted advertising or by sending an opt-out preference signal supported by
your device or browser. Your use of an opt-out preference signal will apply only to your device or browser and
not to other consumer information that is not linked to your device or browser. Please note this Consumer Portal
website does not use tracking technologies for targeted advertising. For more information, or for additional
methods to submit an opt-out request, please view the Consumer Web Portal at
https://consumer.risk.lexisnexis.com/consumer.
Additional Privacy Options for Nevada Residents
As a Nevada resident, you can order additional options under the Nevada Privacy Law. To request any of
the following options, please select the checkboxes that apply to your request:
Notice of Right to Opt-Out: A Do Not Sell My Personal Information request, sometimes referred to as an
opt-out request, will prevent your personal information from being sold to a third party. If you have
previously opted-out but instead want to authorize your personal information to be sold, you may submit
an opt-in request.

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o (Opt-Out) Do Not Sell My Personal Information

o (Opt-In) Allow for the Sale of My Personal Information
Your Social Security Number or your Driver’s License Number and Driver’s License State are.
not required to submit an Opt-Out or Opt-In request. However, providing this information will help us locate
your information and process your request.

Social Security Number + Phone Date of Birth*

* Driver’s License Number+ Driver’s License State+

Please send your completed request form and any supporting documents back to us via U.S. Mail
using the address below:

LexisNexis Risk Solutions Consumer Center

Attn: State Privacy Act Request
P.O. Box 105108
Atlanta, GA 30348-5108
https://consumer.risk.lexisnexis.com/help

Once your request has been received, you will receive a letter via U.S. Mail within two weeks.

SIGNATURE DATE

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