Limit Use of Sensitive or Personal Information – American Health Marketplace

LIMIT THE USE OR DISCLOSURE OF SENSITIVE PERSONAL INFORMATION
Last Updated: 10/29/2024

AMERICAN HEALTH REFORM SOLUTIONS d/b/a AMERICAN HEALTH MARKETPLACE (“we,” “our,” or “us”) may use or disclose your sensitive personal information as described in our Privacy Policy. Please use this form to submit a request to limit our use or disclosure of your sensitive personal information. The information you provide in this form will only be used for the purposes of verifying and processing your request.

Limit Use Form

I am a :

Consumer

Consumer's Authorized Agent

Consumer's First Name

Consumer's Last Name

Consumer's Email Address

Consumer's Phone Number

Consumer's Address

Address

City

State

Country

Any other request details:

Acknowledgement: By submitting this form, you acknowledge that the information you provided is true and accurate.