CALIFORNIA RESIDENTS

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

Checking this box will prevent us from sharing your personal information (such as your name or contact information) with our RadNet family of corporate entity, (significantly limiting the services we provide) because certain state laws consider these exchanges technically a “sale.”

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.

If you are not making this request on your own behalf, please provide the following additional details:

First Name *

Last Name *

Email Address *

Additional Requirements for Authorized Agents

If you are making this request as an authorized agent we will be contacting you for more information. You will need to provide either a written and signed authorization from the California resident indicating you have the authority to submit this request, or a power of attorney from the California resident pursuant to Cal. Prob. Code sections 4000 to 4465.

As required by law, we will contact you to confirm your identity and may ask you to provide additional documentation. Please monitor your inbox for a follow-up email from privacy@radnet.com. We may deny requests from agents that do not submit sufficient proof of their authority to make rights requests. Furthermore, we may require California residents to verify their own identities or confirm that their agents have permission to submit rights requests on their behalf. Requests may be denied if they cannot be verified or confirmed.

Consumer Rights Request Form

If you are not making this request on your own behalf, please provide the following additional details:

Additional Requirements for Authorized Agents

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