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Consumer Request Form
This form only applies to California residents. Do you currently reside in California?*

This form only applies to California residents.

REVENUE AND TAXATION CODE - RTC
DIVISION 2. OTHER TAXES [6001 - 61050] (Heading of Division 2 amended by Stats. 1968, Ch. 279.)
PART 10. PERSONAL INCOME TAX [17001 - 18181] (Part 10 added by Stats. 1943, Ch. 659.)

CHAPTER 1. General Provisions and Definitions [17001 - 17039.3] (Chapter 1 repealed and added by Stats. 1955, Ch. 939.)

17014. (a) “Resident” includes:

(1) Every individual who is in this state for other than a temporary or transitory purpose.

(2) Every individual domiciled in this state who is outside the state for a temporary or transitory purpose.

(b) Any individual (and spouse) who is domiciled in this state shall be considered outside this state for a temporary or transitory purpose while that individual:

(1) Holds an elective office of the government of the United States, or

(2) Is employed on the staff of an elective officer in the legislative branch of the government of the United States as described in paragraph (1), or

(3) Holds an appointive office in the executive branch of the government of the United States (other than the armed forces of the United States or career appointees in the United States Foreign Service) if the appointment to that office was by the President of the United States and subject to confirmation by the Senate of the United States and whose tenure of office is at the pleasure of the President of the United States.

(c) Any individual who is a resident of this state continues to be a resident even though temporarily absent from the state.

(d) For any taxable year beginning on or after January 1, 1994, any individual domiciled in this state who is absent from the state for an uninterrupted period of at least 546 consecutive days under an employment-related contract shall be considered outside this state for other than a temporary or transitory purpose.

(1)For purposes of this subdivision, returns to this state, totaling in the aggregate not more than 45 days during a taxable year, shall be disregarded.

(2)This subdivision shall not apply to any individual, including any spouse described in paragraph (3), who has income from stocks, bonds, notes, or other intangible personal property in excess of two hundred thousand dollars ($200,000) in any taxable year in which the employment-related contract is in effect. In the case of an individual who is married, this paragraph shall be applied to the income of each spouse separately.

(3)Any spouse who is absent from the state for an uninterrupted period of at least 546 consecutive days to accompany a spouse who, under this subdivision, is considered outside this state for other than a temporary or transitory purpose shall, for purposes of this subdivision, also be considered outside this state for other than a temporary or transitory purpose.

(4) This subdivision shall not apply to any individual if the principal purpose of the individual’s absence from this state is to avoid any tax imposed by this part.

(Amended by Stats. 1994, Ch. 1243, Section 4. Effective September 30, 1994.)

California Consumer Privacy Act (CCPA)
California Resident Consumer Request Form

Types of Requests and Definitions

  • Request to Know: A request for information about the categories of personal information we have collected about you, the categories of sources from which we collected the personal information, the purposes for collecting the personal information, the categories of third parties with whom we have disclosed your personal information, and the purpose for which we disclosed your personal information. You may also request information about the specific pieces of personal information we have collected about you.
  • Request to Delete: A request that we delete your personal information that we have collected from you.
  • Request to Opt-Out: A request that we do not sell (share or disclose) your personal information.
  • Request to Opt-In: A request to sell (share or disclose) the personal information about a consumer by a parent or guardian of a consumer less than 13 years of age, by a consumer at least 13 and less than 16 years of age, or by a consumer who had previously opted out of the sale of their personal information.
    For consumers who are less than 13 years of age, a parent or guardian can opt-out of the sale (share or disclose) of their personal information at any time.

Verification Process

This is a process to determine that the consumer making the request is the consumer about whom we have collected the personal information. In order to verify your identity we will, whenever feasible, match the identifying information you provide to the personal information we already maintain. To do this we require the following information from you:

  • Request to Know Categories of Personal Information Collected: Provide your name, email address, date of birth, phone number and home address below.
  • Request to Know Specific Pieces of Personal Information Collected: Provide your name, email address, date of birth, phone number and home address below. Also submit a signed Declaration Form under penalty of perjury verifying your identity.
  • Request to Delete: Provide your name, email address, date of birth, phone number and home address below. Also submit a signed Declaration Form under penalty of perjury verifying your identity.
  • Request to Opt-Out: Provide your name and email address below.
  • Request to Opt-In: Provide your name, email address, date of birth, phone number and home address below. Also submit a signed Declaration Form under penalty of perjury verifying your identity.
    • If the Opt-In request is for a minor under the age of 13, a parent or legal guardian must also submit a Parental Consent Form under penalty of perjury.
Required fields are marked with an asterisk *.

Authorized Agents

If you are acting as an authorized agent for a consumer, we will request written authorization from the consumer or we will accept a legal Power of Attorney under the California Probate Code.

Please indicate here if you are acting as an authorized agent: *
Do you have Power of Attorney?*

If yes, email a copy to CORP.PersonalInformationRequest@HCAHealthcare.com. No additional information is required.

If you don’t have Power of Attorney, provide the following information about yourself:

Name:*

Example: 555-555-5555
Date of Birth:*

Household Requests

Is this a Household Request?*

When making a household request to know specific pieces of personal information about the household or a request to delete household personal information all of the following conditions are required:

  • Each member of the household will have to submit a separate request form;
  • Each member of the household is individually verified;
  • Each member of the household making the request is currently a member of the household; and
  • If a member of a household is a minor under the age of 13, a Parental Consent Form, provided below, is required.

Please provide the following household information:

California Consumer Requests

Provide the following information as required above under “Verification Process”

Name:*

Date of Birth:*

Responding to Requests

How would you like us to respond to your request?*
Do you know the name of the website where you submitted your personal information?*
Were you a patient?*
Please indicate which request(s) you would like to make according to the definitions above:*
Would you like to Opt-In or Opt-Out as described above?*

Additional Information

We will respond to Requests to Delete and Requests to Know within 45 days, unless we need more time in which case we will notify you and may take up to 90 days total to respond to your request. We will act upon Requests to Opt-Out within 15 days.

If you make a Request to Delete, we will not delete personal information on archived or backup systems until the archived or backup system is next accessed or used. We will maintain records of requests that are made that include the date of request, nature of request, manner in which the request was made, the date of our response, the nature of our response, and the basis for any denial of the request if it is denied in whole or in part.

You have indicated that this is a Request to Know Specific Pieces of personal information, Request to Delete, and/or Request to Opt-In. By doing so, the following Declaration of Consumer is required. Please fill out the following Declaration of Consumer.


Declaration of Consumer

I,

Full Name*

a resident of California, in connection with my request to opt-in to the sale of my personal information, to receive the specific personal information collected about me or to delete personal information collected from me for the past 12 months (the "Request") by HCA Healthcare, Inc., do hereby declare, under penalty of perjury under the laws of California and the United States, that I am the consumer whose personal information is the subject of the Request.

This Declaration is made as of this date*
The parties agree that this form is an agreement that may be signed electronically. By completing and submitting this form you consent to the use of electronic signatures. Such signature shall be treated the same as a traditional handwritten signature.

Parental Consent Form

Are you submitting a request for a minor under the age of 13?*
Choose Request Type*
Minor is part of a Household Request*
Minor's Full Name*
Minor's Date of Birth*
Custodial Parent/Guardian Full Name*

I do hereby declare, under penalty of perjury under the laws of California and the United States, that I am the parent or legal guardian of the minor (consumer) whose personal information is the subject of the Request.

Date of Consent*
The parties agree that this form is an agreement that may be signed electronically. By completing and submitting this form you consent to the use of electronic signatures. Such signature shall be treated the same as a traditional handwritten signature.

You may revoke your consent to sell your minor child's personal information at any time. If you desire to revoke this consent, please write down your revocation of consent, and email a copy to CORP.PersonalInformationRequest@HCAHealthcare.com.

The parties agree that this form is an agreement that may be signed electronically. By clicking on the "Submit" box below, this action confirms the parties' consent to the use of electronic signatures and such action shall be treated the same as a traditional handwritten signature.

To obtain a copy of this form click the "Print" button below before clicking "Submit". 

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