Printable Request Form

Printable Request Form
You may order information on yourself by filling out a request, which must include proper identification. If you
have questions or need to submit documents, you can do so 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, andDate of Birth. Depending on the type of request (e.g., a request for your consumer disclosure report), you
may also be required to provide one of the two following optional fields: Social Security Number or Your
Driver’s License Number and State. The information that you provide will only be used by us to verify youridentity and for consumer disclosure purposes. It will not be provided 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, whichis 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 yourinformation. California, Colorado, Connecticut, Montana, Oregon, Texas, Utah, and Virginia residents will receive
both their LexisNexis® Risk Solutions Consumer Disclosure Report (pertaining to the Fair Credit ReportingAct) 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
Risk Solutions 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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Printable Request Form

Additional Privacy Options for California Residents
As a California resident, you have additional options under the California Privacy Rights Act(CPRA). 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 tocertain 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 informationthat 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 Informationo (Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My
Personal Informationo (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 therequirements of the CPA from being processed for purposes of (I) targeted advertising, (ii) the sale of personaldata, and (iii) profiling in furtherance of decisions that produce legal or similarly significant effects concerningyou, 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 fortargeted advertising online.
A Full Opt-Out request will opt-out your personal information from being sold to a third party or used for suchprofiling subject to certain exceptions.
Separately, we also offer a Partial Opt-Out request option. A Partial Opt-Out request will opt-out your personal
information we maintain that is subject to the Colorado Privacy Laws except for any data we have relative to youroccupation 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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Printable Request Formooo(Full Opt-Out): Do Not Sell or Share My Personal Information(Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My
Personal Information(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 therequirements of the CTDPA from being processed for purposes of (I) targeted advertising, (ii) the sale ofpersonal 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 throughour websites for targeted advertising, and we do not sell personal information in our products and services fortargeted advertising online.
A Full Opt-Out request will opt-out your personal information from being sold to a third party or used for suchprofiling subject to certain exceptions.
Separately, we also offer a Partial Opt-Out request option. A Partial Opt-Out request will opt-out your personal
information we maintain that is subject to the Connecticut 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 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 Informationo(Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My Personal
Informationo (Opt-In): Allow for the Sale of My Personal Information
Delete My Personal Information Request

Additional Privacy Options for Montana Residents
As a Montana resident, you have additional options under the Montana Privacy Laws (MTCDPA). 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 therequirements of the Montana Privacy Laws 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 share personal information in our products andservices for targeted advertising online.
A Full Opt-Out request will restrict your personal information from being sold to a third party subject to certain
exceptions.
Separately, we also offer a Partial Opt-Out request option. A Partial Opt-Out request will opt-out yourpersonal information we maintain that is subject to the Montana Privacy Laws except for any data we haverelative 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 theMontana 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 Montana Privacy Rights page. https://consumer.risk.lexisnexis.com/montana

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Printable Request Formooo(Full Opt-Out): Do Not Sell or Share My Personal Information(Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My
Personal Information(Opt-In): Allow for the Sale of My Personal Information
Delete My Personal Information Request

Additional Privacy Options for Oregon Residents
As an Oregon resident, you have additional options under the Oregon Consumer Privacy Act (OCPA). 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 therequirements of the Oregon Privacy Laws 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 share personal information in our products andservices for targeted advertising online.
A Full Opt-Out request will restrict your personal information from being sold to a third party subject to certain
exceptions.
Separately, we also offer a Partial Opt-Out request option. A Partial Opt-Out request will opt-out your personal
information we maintain that is subject to the Oregon Privacy Laws except for any data we have relative to youroccupation 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 Oregon
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 Oregon Privacy Rights page. https://consumer.risk.lexisnexis.com/oregono (Full Opt-Out): Do Not Sell or Share My Personal Informationoo(Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My
Personal Information(Opt-In): Allow for the Sale of My Personal Information
Delete My Personal Information Request

Additional Privacy Options for Texas Residents
As a Texas resident, you have additional options under the Texas Data Privacy and Security Act (TDPSA).
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
Texas Privacy Laws 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 fortargeted advertising, and we do not share personal information in our products and services for targeted
advertising online.
A Full Opt-Out request will restrict your personal information from being sold to a third party subject to certain
exceptions.
Separately, we also offer a Partial Opt-Out request option. A Partial Opt-Out request will opt-out your personal
information we maintain that is subject to the Texas Privacy Laws except for any data we have relative to youroccupation 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 Texas
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 Texas Privacy Rights page. https://consumer.risk.lexisnexis.com/texas
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Printable Request Formooo(Full Opt-Out): Do Not Sell or Share My Personal Information(Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My Personal
Information(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 therequirements of the UCPA from being processed for purposes of (I) targeted advertising, and (ii) the sale ofpersonal 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 andservices for targeted advertising online.
A Full Opt-Out request will opt-out your personal information from being sold to a third party subject tocertain exceptions.
Separately, we also offer a Partial Opt-Out request option. A Partial Opt-Out request will opt-out your personal
information we maintain that is subject to the Utah Privacy Laws except for any data we have relative to youroccupation 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 Rights page. https://consumer.risk.lexisnexis.com/utaho (Full Opt-Out): Do Not Sell or Share My Personal Informationoo(Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My Personal
Information(Opt-In): Allow for the Sale of My Personal Information
Delete My Personal Information Request

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 therequirements of the VCDPA from being processed for purposes of (I) targeted advertising, (ii) the sale of personaldata, 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 fortargeted 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 suchprofiling subject to certain exceptions.
Separately, we also offer a Partial Opt-Out request option. A Partial Opt-Out request will opt-out your personal
information we maintain that is subject to the Virginia Privacy Laws except for any data we have relative to youroccupation 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 Rights page at https://consumer.risk.lexisnexis.com/virginia

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Printable Request Formoo(Full Opt-Out): Do Not Sell or Share My Personal Information(Partial Opt-Out): Allow for the Sale of My Professional Information but otherwise Do Not Sell My Personal
Informationo (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, Montana, Oregon, Texas, Utah, or Virginia resident, in somecircumstances 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 ofyour 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.
As a California, Colorado, Connecticut, Montana, Oregon, Texas, 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 orbrowser. 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 (NPL). 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.
o (Opt-Out) Do Not Sell My Personal Informationo (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 +* Driver’s License Number+Phone

Date of Birth*

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 we have received your request, it will take approximately two weeks to process and send you a letter with a
PIN and URL to access your report online. You may also choose to receive a hardcopy of your report via U.S.
Mail.

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