Privacy Rights Request Form

We take your privacy seriously and do not sell or share personal information (PII) or protected health information (PHI). We use and disclose information only as permitted by applicable law, including the Health Insurance Portability and Accountability Act (HIPAA). Use this form to submit a request regarding your medical record or personal information, or to ask a privacy question.

First Name

Last Name

Email Address

Phone Number

Address

State of Residence

Consumer Relationship to RadNet

Date of birth

Patient ID or Account Number

Deactivate my patient portal account

HIPAA Rights Request—“I’m making a request related to my medical record.”

Request a copy of medical record

Log into your Patient Portal https://www.radnet.com/medical-records
Contact the imaging center where your exam was performed
Contact your referring provider

Request an amendment to your medical record

If you believe administrative information in your medical record is inaccurate or incomplete, you may submit an amendment request here.

Examples of appropriate administrative requests include:

Correcting or removing inaccurate contact information contained within the patient’s record.
Updating provider information when a physician is no longer involved in the patient’s care and should not receive future reports.
Addressing administrative issues related to prior examinations, such as concerns regarding comparisons to unrelated or incorrectly referenced studies.

Note: These types of requests involve the accuracy and maintenance of the medical record itself and do not require reconsideration of a radiologist’s professional interpretation of imaging findings. Questions or disagreements regarding the radiologist’s report should be addressed through your referring physician. If the referring physician determines that further review is appropriate, they may consult directly with the interpreting radiologist through the established physician-to-physician communication process.

Request a restriction on uses/disclosures of my medical record

Request an accounting of disclosures

State Consumer Privacy Laws Rights Request—“I’m making a request related to my personal information not part of my medical record.”

Request an accounting of personal information we store

Request a correction of personal information

Request deletion of personal information (We honor deletion requests for personal information not part of your medical record. Medical records are retained as required by law for patient safety and compliance purposes.)

See our HIPAA Notification for more information. Consumers can review how RadNet uses and discloses other identifiable information in our Privacy Statement.
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Ask a Privacy Rights Question

Type of Requester(check one):

I hereby certify under penalty of perjury 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 representative acting on behalf of a patient, business partner, or consumer who has authorized me to make this request.

First Name

Last Name

Relationship to Individual