Privacy & contact permission

Updated September 29, 2026

What this form collects

We collect your name, phone number, ZIP code, optional email address, and optional preferred callback time to respond to your request for help finding care. We also store the time and version of your contact permission. Do not submit medical information, identification numbers, or insurance details.

How we use and store your request

Requests are stored in the Wreck Doctors team inbox and emailed to ideaman7771@yahoo.com so the team can respond. FormSubmit handles email delivery and may retain submissions for up to 30 days. Hosting and email service providers process the data to operate this form. Read FormSubmit’s privacy information.

Your choice

Submitting permits Wreck Doctors to use your contact details to respond to this request by phone or email. It does not authorize automated marketing, marketing texts, or sending your information to a doctor or lawyer. Separate permission is required before sharing your details for a referral. You may decline a referral or contact a provider independently.

Access, correction, and deletion

Call 1-800-595-PAIN or email ideaman7771@yahoo.com to request access, correction, deletion, or to withdraw your callback permission. Records are kept until the team processes a deletion request or removes them under its retention practices; automatic deletion is not currently enabled. Messages delivered by email may need to be deleted from the recipient mailbox separately.

Public directory

Provider records come from public government sources. They do not contain patient records. Contact us to report a directory error and update the underlying NPI record with CMS where appropriate.

Emergencies and children

This form is intended for adults requesting a callback. It is not a clinical intake system or emergency service. Call 911 for emergencies.