Sutter Gould Online Form PDF Details

In a healthcare environment where the confidentiality and access to medical records are governed by a complex web of state and federal laws, mechanisms that facilitate authorized access to a minor's health information become essential tools for effective and compassionate care. The Sutter Gould form presents a meticulously designed authorization process, enabling a stepparent to gain access to the medical records of their minor stepchild. This form is an embodiment of the legal and ethical considerations that healthcare providers must navigate, ensuring that the access provided aligns with both the best interest of the child and the regulatory requirements laid out by authorities. It requires detailed information from both the natural parent or guardian and the stepparent, reinforcing the safeguarding of the child's health information. Specifically, it stipulates the completion of several fields, including personal and contact information for all parties involved, and underscores the limited scope of access granted – that is, solely through the My Health Online platform. This delineation of access underscores a thoughtful approach to privacy, ensuring that the stepparent's interaction with the child's health data is both necessary and appropriate for the child's wellbeing. Furthermore, the form outlines the duration of the authorization, how it may be terminated, and the rights of the parties involved, including their right to revoke the authorization and the limitations on further disclosure of the information. By walking through the stipulations, requirements, and legal assurances provided in the Sutter Gould form, we gain insight into a system designed to balance the intricacies of law, the rights of parents and guardians, and the paramount importance of protecting the health and privacy of minors in the healthcare system.

QuestionAnswer
Form NameSutter Gould Online Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessutter gould dme authorization form, sutter gould authorization form, sutter gould form, sutter gould medical foundation authorization form

Form Preview Example

SUTTER HEALTH USE ONLY

MRN:

DOB:

Doc Type:

DOS:

Written Authorization for a Stepparent to Access the Medical Record of a Minor Child

This request for written permission is required by state and federal law.

Please complete all fields and print legibly to ensure timely processing.

Patient Name

 

 

 

 

 

 

 

 

 

 

(Under age 12)

 

 

 

 

 

 

 

 

 

 

Last

 

 

First

 

 

 

MI

Phone

 

SSN

 

 

 

DOB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 digits only

 

 

 

 

 

I grant authorization to the following individual to access the health information in My Health Online, for the patient named above:

Stepparent

Street Address

City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

SSN

 

 

 

DOB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 digits only

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Natural Parent or Guardian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

SSN

 

 

 

DOB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 digits only

 

 

 

 

 

E-mail Address

Relationship to patient named above:

SUTTER HEALTH USE ONLY

Parent/Stepparent Verified By:

Natural Parent

Date:

Guardian

Page 1 of 2

SUTTER HEALTH USE ONLY

MRN:

DOB:

Doc Type:

DOS:

The recipient may use the health information only for the following purpose:

To access medical information and services on behalf of a minor child via My Health Online. This authorization does NOT allow the proxy representative to access the patient’s health information other than via My Health Online.

I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment. This authorization shall remain valid until terminated electronically or in writing by My Health Online, the proxy representative or once the child reaches 12 years of age, whichever comes first. If written, the revocation must be signed on the patient’s behalf and sent to the Patient Services Contact Center. The revocation is effective upon receipt, but will have no impact on uses or disclosures made while the authorization was valid.

Restriction: California law prohibits the proxy representative from making further disclosure of your health information unless the recipient obtains another authorization from you or unless the disclosure is required or permitted by law. This protection does not extend to recipients outside the state of California.

I HAVE A RIGHT TO A COPY OF THIS AUTHORIZATION.

Copy requested Yes

No

Copy received

Yes

No

Natural Parent/Guardian Signature

 

Date

 

 

 

 

Stepparent Signature

 

Date

 

 

Fax to: (877) 607-6484

 

 

Mail to: Patient Services Contact Center

 

 

ATTN: My Health Online Proxy

 

 

P.O. Box 255386

 

 

Sacramento, CA 95865-5386

SUTTER HEALTH USE ONLY

Parent/Stepparent Verified By:

 

Date:

Page 2 of 2

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Writing segment 1 of sutter gould prior authorization form

2. Once this section is completed, proceed to type in the suitable details in all these: Email Address, Natural Parent or Guardian, Street Address, City, Phone, Email Address, Last digits only, State, Zip Code, SSN, DOB, Last digits only, Relationship to patient named above, Natural Parent, and Guardian.

Guardian, Street Address, and Phone of sutter gould prior authorization form

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