McKinleyville: (707) 840-0226 Crescent City: (707) 464-3245
Two Northern CA Locations  |  Mon–Fri

Privacy Rights Request Form

Use this form to exercise your rights under HIPAA and the California Confidentiality of Medical Information Act. All requests are reviewed within 30 days.

⚠️ This form is for privacy rights requests only — not for medical questions or appointment scheduling. For clinical matters, please call the office directly. Do not include sensitive medical details (diagnoses, medications, test results) in this form.

Fields marked * are required.

Your Information

Required if you are requesting a written response by mail.

Type of Request *
Request Details
Identity Verification

We are required to verify your identity before processing any privacy rights request. You will be contacted to complete identity verification before your request is fulfilled. Do not submit government ID or other sensitive documents through this form.

Certification
Please complete all required fields before submitting.

Request Received

Thank you. Your privacy rights request has been submitted. A staff member will contact you within 30 days — sooner for urgent matters. If you have questions in the meantime, please call the office directly.

McKinleyville: (707) 840-0226    Crescent City: (707) 464-3245

Response Time
30 Days
from receipt of complete request
Governed By
HIPAA & CMIA
California & federal law
Prefer to Call?
Need to file a complaint with HHS? You also have the right to file a complaint directly with the U.S. Department of Health & Human Services, Office for Civil Rights, at hhs.gov/ocr or by calling 1-877-696-6775. We will not retaliate against you for filing a complaint.

Questions About Your Privacy Rights?

Call either office or email us — we are happy to walk you through the request process.

McKinleyville: (707) 840-0226 Crescent City: (707) 464-3245