Consumer Rights Request Form

If you reside in California and would like to make a request related to your personal information, please fill out the form below. In addition to filling out and submitting this form, California residents may make such requests using one of the contact methods listed below. If you would like to be removed from our promotional communications, contact us or click on the “unsubscribe” button located at the bottom of RadNet’s promotional email communications or reply “STOP” to any RadNet texts.

First Name

Last Name

Email Address

Phone Number

State of Residence

Deactivate my patient portal account

Consumer Relationship to RadNet

Type of Request(s) (check all that apply):

Request information about how we collect, use, sell, and share categories of personal information about you

Request access to your personal information

Request deletion of your personal information

Opt-out of the sale of your personal information

RadNet does not sell patient information, see our HIPAA Notification for more information. Consumers can review how RadNet uses and discloses other identifiable information in our Privacy Statement.

Type of Requester(check one):

I hereby certify under penalty of perjury that I am a California resident and that I am making this request on my own behalf.

I am the parent/legal guardian of the minor who is the subject of this request.

I am an authorized agent acting on behalf of a California resident who has authorized me to make this request.

First Name

Last Name

Email Address

Consumer Rights Request Form

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