Commitment to safety and outstanding patient care.
Always ready to respond when it matters most.
Our patient advocates are standing by.
We reserve the right to refuse requests for various reasons, including: (a) to the extent permitted by law; (b) if we are unable to verify your identity; or (c) if we cannot verify your authority to act on behalf of another person.
Please submit your request through the form below.
Please Select Who the Request Is Being Made For:
If you are completing this form as an Authorized Agent, please complete and send us a California Authorized Agent Designation Form.
If you are submitting this form as an Authorized Agent, please complete the following information:
Please specify your request. For more information on the below, please visit our CCPA Notice:
By checking “I Accept” below, you acknowledge and certify that the information you have entered into this form is complete and accurate to the best of your knowledge, and that you are either (a) a California resident making this request on behalf of yourself; or (b) an Authorized Agent making this request on behalf of a California resident, as indicated above. You understand that it may be necessary for us to further verify the identity of the California resident and/or the Authorized Agent and you agree to comply with any such requests.