Sutter Gould Online Form PDF Details

If you need to get a medical form filled quickly and easily, look no further than Sutter Gould's Online Form. With its fast and secure functionality, the online form has become a popular choice for healthcare providers looking for an efficient way to manage their forms. And with the added convenience of being able to complete the process any time from the comfort of your own home or office, it's no wonder why this method is gaining in popularity each day. Learn more about how this innovative tool can help streamline your daily operations today!

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

3. This next part will be focused on Copy requested, Yes, Copy received, Yes, Natural ParentGuardian Signature, Stepparent Signature, Date, Date, Fax to, Mail to Patient Services Contact, SUTTER HEALTH USE ONLY, Date, and Page of - type in each of these blank fields.

Completing segment 3 of sutter gould prior authorization form

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