PracticeMatch California Consumer Request Form for Exercise of Rights Under California Consumer Privacy Act

Please Complete the Information Below

When you have completed the required information, submit the form by clicking "submit" at the bottom. After receiving this form, we will be in touch to verify your identity and respond.

1. Complete the following information of the person whose information is the subject of this request:

Name is required
Phone Number is required
Email is required
City and State of Residency is required

2. Request Type [check all that apply]:

Select all that apply

3. Additional Details. Please help us understand your request by providing additional details below.:

If Submitted On Behalf of A Consumer: provide via email ( the Authorized Agent's name and written permission or a Power of Attorney ("POA") from the consumer this request concerns (a free copy of California's Uniform Statutory POA is found here:
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