CCPA Form

Are you a current or previous member of Health Net, California Health & Wellness or one of Health Net’s subsidiary plans? *

Yes No

If “Yes”, your information is excluded from the CCPA's scope and your information is protected by the federal and state regulatory statutes that are listed below:

Health or medical information covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the California Confidentiality of Medical Information Act (CMIA) or clinical trial data;
Personal information covered by certain sector-specific privacy laws, including the Fair Credit Reporting Act (FRCA), the Gramm-Leach-Bliley Act (GLBA) or California Financial Information Privacy Act (FIPA), and the Driver's Privacy.

Please select an option *

Request an Accounting (report) of my personal information Request Deletion of my personal information Opt-Out of Sale of my personal information

First Name *

Last Name *

Social Security Number – SSN Please provide the last 4 numbers of your Social Security Number, for verification purposes only.

Please Note: At least two forms of communication need to be provided to process a CCPA request.

Primary form of contact *

Email Telephone Mail Address

Secondary form of contact *

Telephone Mail Address

Secondary form of contact *

Email Mail Address

Secondary form of contact *

Email Telephone

Email *

Phone Number *

Address *

City *

State/Province/Region *

ZIP/Postal Code *

Additional Information: Please provide any additional information that you feel would be necessary.

This form will send your message to Health Net as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Health Net through email, you accept associated risks. Health Net does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please call our member services.

California Consumer Privacy Rights Request Form