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Data Subject Access Request (DSAR) Form
DSAR
Are you making this request in person?
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Yes, in person
No, by proxy
Your rights as a data subject can be exercised by completing this form and submitting it.
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Terms
I accept the Terms & Conditions.
By completing this form, you consent that ProHealth HMO Limited would use your personal data to process your request and provide you with relevant response to your inquiries and request. Your rights as a data subject can be exercised by completing this form and submitting it.
Date
Date of request
Name
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Details of person requesting the data (Please attach a valid means of identification)
Phone
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Email
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Date
*
Date of birth
Name
Details of proxy (If applicable) requesting the data (Please attach a valid means of identification)
Phone
Address
Contact address of proxy
Email
Date
Date of birth
Relationship to the data subject:
A Proxy must enclose a copy of a power of attorney or data subject’s written authority and proof of the data subject’s identity and proxy’s identity (such as Passport, driving license, national identity card, birth certificate etc.)
Any information that may assist with the processing of this request
Add any additional information
Right of Access
Tick if appropriate
Right to Erasure
Tick if appropriate
Right to Portability
Tick if appropriate
Right to Restriction of Process
Tick if appropriate
Right to Object
Tick if appropriate
Right to Rectification
Tick if appropriate
Details of Request:
Please describe the information you are seeking. Please provide any relevant details you think will help us to identify the information you require.
Feedback Medium
Select
Email on record
Letter to correspondence address on record
Pick up from the Head Office
Choose preferred feedback medium
Terms & conditions
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Terms
I accept the Terms & Conditions.
I confirm that I have read and understood the ProHealth HMO Limited’s Data Privacy Policy available at [Insert link to the webpage]. In consideration of all the information stated herein, I certify that the information provided in this form is correct to the best of my knowledge and that I am the person to whom it relates.
Proof of Identity
Allowed types : .pdf, .png, .doc, .xml, .jpg, .txt, .csv, .webp, .zip, .xlsx
Maximum file size allowed is 500 KB
Any valid government ID
Power of Attorney or Authority Letter from Data Subject
Allowed types : .pdf, .png, .doc, .xml, .jpg, .txt, .csv, .webp, .zip, .xlsx
Maximum file size allowed is 500 KB
Upload power of Attorney or Authority Letter from data subject
