Data Subject Access Request Form

Website

Full Name *

What email address do you use to access the above website / app? *

You are submitting this request as *

The person, or the parent / guardian of the person, whose name appears above.

An agent authorized by the consumer to make this request on their behalf.

Under the rights of which law are you making this request? *

Please leave details regarding your action request or question. *

I confirm that

Under penalty of perjury, I declare all the above information to be true and accurate.

I understand that the deletion or restriction of my personal data is irreversible and may result in the termination of services with Critical Care Telemedicine, PLLC

Michael Dinkels, MD

Board Certified in Critical Care Board Certified in Pulmonology Board Certified in Internal Medicine

Professional Affiliations

Society of Critical Care Medicine

American College of Physicians

American Telemedicine Association

Contact Us

(518) 360-1247

[email protected]

1971 Western Ave, #197
Albany, NY 12203

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