Legal

Privacy and Data Request

Use this form to exercise your privacy rights. We may need to verify your identity before fulfilling your request.

Some records may need to be retained for clinical, legal, billing, or compliance reasons. See our Data Retention page and Privacy Policy for more information.

This form is not monitored for emergencies. If you are in crisis or need immediate help, call 911 or 988, or go to the nearest emergency room. More crisis resources

First name

Last name

Phone (optional)

Request type

Your relationship to Pothos Health

State of residence

Additional details (optional)

I confirm that I am at least 18 years old.

I understand that Pothos Health may need to verify my identity before fulfilling this request.

See our Privacy Policy for more information about your rights.