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Consumer Request Form
This form only applies to California residents. Are you a California resident?*

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 General Provisions and Definitions [17001 - 17039.3] (Chapter 1 repealed and added by Stats. 1955, Ch. 939.)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) of 2018 as Amended by the California Privacy Rights Act (CPRA)
California Resident Consumer Request Form

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 and/or use a third-party identity verification service. To do this we require the following information from you:

  • Request to Know What Categories of Personal Information is Being Collected. Provide your name and email address below.
  • Request to Know the 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 Correct Inaccurate Personal Information: 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 Limit the Use and Disclosure of Sensitive Personal Information: Provide your name and email address below.
  • Request to Opt-Out of the Sale or Sharing of Personal Information: Provide your name and email address below.
  • Right to Opt-In. You may choose to opt-in after opting-out of the sale or sharing of your Personal Information if a Service requires the sale or sharing of your Personal Information.

Required fields are marked with an asterisk *

Authorized Agents

Please indicate here if you are acting as an authorized agent: *
If yes, which of the following applies to you:*

Send authorizing documentation to CORP.PersonalInformationRequest@HCAHealthcare.com.

California Consumer Request

Full Name (First, Middle, and Last)*

Zip Code*
Date of Birth:*
Are you a current or former employee, applicant, independent contractor, medical staff, owner, director, officer, a beneficiary or an emergency contact?*
How would you like us to respond to your request?*
Please indicate what type of request(s) you would like to make:*
Please indicate which request(s) you would like to make according to the definitions above:*

Minors

We do not have actual knowledge that we sell or share the Personal Information of Consumers who are less than 16 years of age. However, if we have actual knowledge that the Consumer is less than 16 years of age, we will not sell or share the Consumer’s Personal Information unless the Consumer in the case of Consumers who are at least 13 years of age and less than 16 years of age, or the Consumer’s parent or guardian, in the case of Consumers who are less than 13 years of age, has affirmatively authorized the disclosure of the Consumer’s Personal Information.

Timing

We will respond to Requests to Know or Access Personal Information, Request to Know the Specific Pieces of Personal Information Being Collected, Requests to Delete Your Personal Information and Requests to Correct Inaccurate Personal Information no later than 45 calendar days after we receive the request, 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 respond to Requests to Opt-Out of the Sale or Sharing of your Personal Information and Requests to Limit the Use and Disclosure of Sensitive Personal Information no later than 15 calendar days after we received your request.

Requests for a Minor

Are you submitting a request for a minor?*

Parental Consent Form

Custodial Parent/Guardian Full Name*

Zip Code*
Custodial Parent/Guardian Date of Birth *
Minor's Full Name*
Minor's Address*
Address 2
City*
Zip Code*
Minor's Date of Birth*

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.

Declaration of Consumer

I,

a resident of California, in connection with my request to opt-in to the sale or sharing of my personal information, to receive the specific pieces of personal information collected about me, to correct inaccurate personal  information or to delete personal information collected from me since January 1, 2022 (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 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.

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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