Fillable Form 2020: Medical Record Authorization Form Instructions How

Fill Online, Printable, Fillable, Blank Form 2020: Medical Record Authorization Form Instructions How Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 2020: Medical Record Authorization Form Instructions How

On average this form takes 11 minutes to complete

The Form 2020: Medical Record Authorization Form Instructions How form is 4 pages long and contains:

  • 1 signature
  • 35 check-boxes
  • 25 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Medical
Record
Authorization
Form
Instructions
September
2020
1 | Page
►Important: Please download and save a copy of this form before filling it out.◄
How to Complete the Medical Record Authorization Form
Are you the patient?
o Answer “Yes” if you are the patient or “No” if you are the patient’s legal or personal representative.
NOTE: If you answer “No”, you may be asked to provide supporting documentation that gives you the authority
to request medical records on the behalf of the patient.
Patient Information
o Enter the patient’s First and Last Name, Middle Initial (if any), full address, date of birth, phone number, and the
patient’s email address (required for contact purposes)
Who do you want us to request your records from?
o Enter the name of the Sutter Health facility or Sutter doctor’s full name, address, phone number and fax number.
Where do you want the records sent to?
o Check the box if you want records sent to the patient only. You can skip to the next section.
o If records will be sent to someone other than the patient, enter the recipient’s full name, address, city, state, zip code,
recipient phone number, recipient fax or email.
What is the reason for requesting records?
o Choose the appropriate reason for requesting records. Check only one.
What treatment dates of service are you looking for?
o List the approximate date range for the treatment dates of service you need to the best of your ability.
What types of records would you like? (Check all that apply).
o Clinic/Doctor’s Office Visit Notes – ALL Providers: Select only if you want notes from any physician you may have
seen.
o Following Specific Providers(s) ONLY: Select only if you want notes from a specific doctor’s visit. Please give us
the name of your provider to expedite your request.
o Hospital Records: Select only if you want records from inpatient hospitalizations or emergency room visits at one of
our hospitals.
o Immunizations: Select only if you want immunization/vaccination records (e.g. flu shots, DTAP, etc.).
o Lab Test Results: Select only if you want your most recent lab test results (e.g. urinalysis, CBC, etc.).
o Radiology Reports (CT, MRI, X-ray, etc.): Select only if you want a copy of your radiology exam results (printed
form). NOTE: To request radiology images, visit https://www.sutterhealth.org/for-patients/request-medical-record
and
click on the appropriate link.
o Operative Reports/Procedure Notes: Select only if you want copy of the operative report or procedure note for your
most recent surgery or procedure.
o Physical/Occupational/Speech Therapy Records: Select only if you want copy of your most recent physical therapy,
occupational therapy, or speech therapy records.
o Home Health Records (Sutter Care At Home): Select only if you want records related to visits with home health
caregivers through Sutter Care at Home.
o Other: Select only if you are seeking records not listed above. You can provide specific details in the next section.
2 | Page
Please describe the specific records you’re requesting to help us respond more completely to your request. (Example:
related to a condition or surgery, specific lab tests, all available records, etc.).
o This section is optional. Enter additional details as desired related to the types of records you need.
Do we have permission to release the following protected information that may be contained in your medical records?
o Please check all that apply. Leave blank if none of them apply to you.
Is there a deadline for this request?
o Answer “Yes” if you have a deadline along with the date you need the records of answer “No” if you don’t have a
specific deadline.
NOTE: California law allows healthcare providers up to 15 days to fulfill your request.
How would you like us to send the records? *Must select one (1) option ONLY
o Tell us how you would like to receive the records. Check only one option from the list.
Expiration Date (Optional). The authorization will be effective for one year from the date you sign it unless you specify
otherwise. You have the right to give us an alternative expiration date. However, if you do, it must be dated at least 15 days in
the future from Today’s date to allow ample time to process your request as permitted by California law.
Your Rights Under the Law. This section is informational only. It explains your rights under state and federal privacy laws.
Signature and Date. Your signature and date is required for the authorization to be valid. If you are completing the
authorization on behalf of the patient, please print your name and your relationship to the patient.
Additional Requirements:
Photo ID: For your protection, please include a legible copy of a photo ID or other government-issued ID along with the
authorization form for identity verification purposes. If you will be picking up your records in-person, you will be asked to provide
your Photo ID at that time.
If Someone Other Than the Patient: In addition to a Photo ID, please include copy of supporting documentation that gives you
authority to request records on behalf of the patient. Acceptable forms of documentation include: Death Certificate, Executor
of the Estate (for deceased patients only), Power of Attorney (must include a provision that allows medical decision-making
and/or release of medical records), Power of Attorney for Health Care (must include a provision that allows release of medical
records), or some other form of documentation (subject to final review).
Thank you for selecting Sutter Health as your provider of choice.
AUTHORIZATION FOR USE AND
DISCLOSURE OF HEALTH INFORMATION
PATIENT LABEL
SH-0009 (08.18.2020)
AUTHORIZATION FOR USE AND
DISCLOSURE OF HEALTH INFORMATION
PATIENT LABEL
SH-0009 (08.18.2020)
Page 1 of 2
1000
HIM ROI
AUTHORIZATION
Are you the Patient?
Yes No, I’m the patient’s legal/personal representative*
*Note: If you’re not the patient, you may be asked to provide supporting documentation to verify that you are
authorized to make this request on behalf of the patient.
Patient Information
Patient Name: Date of Birth:
Address, City, State, ZIP:
Patient Phone: Email:
Who do you want to request records from?
Healthcare Provider or Facility Name:
Address, City, State, ZIP:
Phone: Fax:
Where do you want the records sent to? Note: We can release information only to who you authorize.
Check this box if records are being sent to the patient only. No further action in this section needed
.
Recipient Name:
Recipient Address, City, State, ZIP:
Recipient Phone: Recipient Fax or Email:
What is the reason for requesting records?
I’m moving and/or switching doctors Getting a second opinion Seeing a Specialist
Military Enlistment Personal Use Other reason:
What treatment dates of service are you looking for?
Specify an approximate* date range – Start:
/
/ to End:
/
/
*Date range doesn’t have to be exact. Enter dates to the best of your ability.
What types of records would you like? Note: Some records may only be available on paper or PDF.
Clinic/Doctor’s Office Visit Notes – ALL Providers OR Following Specific Provider(s) ONLY:
Hospital Records Immunizations Lab Test Results Radiology Reports (CT, MRI, X-ray, etc.)
Operative Reports/Procedure Notes Physical/Occupational/Speech Therapy Records
Home Health Records (Sutter Care at Home) Other (Please specify)
Please describe the specific records you’re requesting to help us respond more completely to your
request. (Example: related to a condition or surgery, specific lab tests, all available records, etc.)
Do we have permission to release the following protected information* that may be contained in your
records? Please check all that apply below. *Additional authorization may be required.
HIV Test Results
Mental Health Records
Substance Use/Drug Abuse Records
Genetic Testing Results
AUTHORIZATION FOR USE AND
DISCLOSURE OF HEALTH INFORMATION
PATIENT LABEL
Page 2 of 2
SH-0009 (08.18.2020)
Is there a deadline for this request?
By law we have up to 15 days to fulfill your request. However, if you have an urgent need for an upcoming
appointment, please let us know. We will do our best to honor your deadline.
Yes, I have a deadline. Date needed: No, just as soon as possible.
How would you like us to release the records? *Must select one (1) option ONLY
Patient Portal (My Health Online) Email (encrypted) Email (unencrypted)*
Fax (50-page limit) CD (encrypted) by Mail CD (encrypted) by In-Person Pickup
Per Page Fees May Apply: Paper by Mail Paper by In-Person Pickup
For Additional Fee: USB flash drive (encrypted) by Mail USB flash drive (encrypted) by In-Person Pickup
*Sending information by unencrypted email increases the risk of being read by an unauthorized third party.
Expiration Date
This authorization shall become effective immediately and remain in effect for one (1) year from the date signed
below unless specified here*:
*
Optional Expiration Date (must be at least 15 days in the future from Today’s date to be valid)
Your Rights Under the Law
•
I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment or payment.
• I may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf,
and mailed to this address:
o
Sutter Shared Services, Attn: Release of Information, P.O. Box 619091, Roseville, CA 95661
• My revocation will be effective upon receipt, but will have no impact on uses or disclosures made while my
authorization was valid.
• I have the right to receive a copy of this authorization.
• I may inspect and obtain copy of my health information for which I am authorizing the use or disclosure for
as long as the information is maintained by the affiliate(s) listed above.
• The location(s) listed above will not receive compensation for the use or disclosure of my health information.
• I understand that California law prohibits the recipients of my health information from making further disclosure
of my health information unless the recipient obtains another authorization from me or unless the disclosure
is required or permitted by law. This protection does not extend to recipients outside the state of California.
SIGNATURE AND DATE (As required by law)
SIGNATURE: Date: Time:
(Patient or Legal/Personal Representative*)
*If signed by someone other than the patient, print name and specify relationship to the patient:
Name: Relationship:
NOTE: To request Billing Records or Radiology Images,
visit https://www.sutterhealth.org/for-patients/request-medical-record and click on the appropriate link.
click to sign
signature
click to edit
Sutter Health Facility Listing (Hospitals and Clinics/Foundations) for Requesting Medical Record Copies
Facility Name Mailing Address City State Zip Fax Email
Alta Bates Comprehensive Cancer Center, Berkeley 2001 Dwight Way Berkeley CA 94704 (510) 204-2043 S3ROIDept@sutterhealth.org
Alta Bates Summit Medical Center – Ashby & Herrick Campuses, Berkeley 2450 Ashby Ave - Room 1140 Berkeley CA 94705 (510) 841-8818 S3ROIDept@sutterhealth.org
Alta Bates Summit Medical Center – Summit & Providence Campuses,
Oakland
350 Hawthorne Ave. Oakland CA 94609 (510) 655-8114 absmc-summithimroiteam@sutterhealth.org
California Pacific Medical Center – California/Davies/Pacific/Van Ness
Campuses, San Francisco
3700 California St. Ste. 1570 San Francisco CA 94118 (916) 736-5499 S3ROIDept@sutterhealth.org
California Pacific Medical Center – St. Luke’s/Mission Bernal Campus, San
Francisco
3555 Cesar Chavez St. San Francisco CA 94110 (916) 736-5499 WBMBHIM@sutterhealth.org
California Pacific Medical Center – Transplant Program, San Francisco 3883 Airway Dr. Ste. 320 Santa Rosa CA 95403 (707) 573-5407 spmfhimsr@sutterhealth.org
California Pacific Medical Center – Whitney Clinic, San Francisco 1625 Van Ness St. - 3rd Floor San Francisco CA 94109 (916) 736-5499
S3ROIDept@sutterhealth.org
Eden Medical Center Outpatient Rehabilitation Services, San Leandro 14207 14th St. San Leandro CA 94578 (916) 736-5499
S3ROIDept@sutterhealth.org
Eden Medical Center, Castro Valley 20103 Lake Chabot Rd. Castro Valley CA 94546 (916) 736-5499
S3ROIDept@sutterhealth.org
Kalmanowitz Child Development Center, San Francisco/San Rafael 4000 Civic Center Dr. Ste. 210 San Rafael CA 94903 (916) 736-5499
S3ROIDept@sutterhealth.org
Lafayette Women's Health, Lafayette 3595 Mt. Diablo Blvd. Lafayette CA 94549 (510) 841-8818
S3ROIDept@sutterhealth.org
Los Banos Rural Health Clinic, Los Banos 1253 I Street Los Banos CA 93635 (916) 736-5449
S3ROIDept@sutterhealth.org
Memorial Hospital Los Banos, Los Banos 520 I Street Los Banos CA 93635 (916) 736-5499
S3ROIDept@sutterhealth.org
Memorial Medical Center, Modesto 1700 Coffee Rd. Modesto CA 95355 (916) 736-5499
S3ROIDept@sutterhealth.org
Menlo Park Surgical Hospital, Menlo Park 570 Willow Rd. Menlo Park CA 94025 (916) 736-5499
S3ROIDept@sutterhealth.org
Mills Peninsula Medical Center, Burlingame 1501 Trousdale Drive Burlingame CA 94010 (916) 736-5499
S3ROIDept@sutterhealth.org
Mills Health Center, San Mateo 100 S. Mateo Dr. San Mateo CA 94401 (916) 736-5499
S3ROIDept@sutterhealth.org
Novato Community Hospital, Novato 180 Rowland Way Novato CA 94945 (916) 736-5499
S3ROIDept@sutterhealth.org
Novato Community Hospital: Physical Therapy & Sports Fitness, Novato 100 Rowland Way Novato CA 94945 (916) 736-5499
S3ROIDept@sutterhealth.org
Palo Alto Medical Foundation (PAMF) Clinics/Doctor’s Offices – Camino
Division
701 E. El Camino Real Mountain View CA 94040 (408) 524-5034 PAMFROIDept@sutterhealth.org
Palo Alto Medical Foundation (PAMF) Clinics/Doctor’s Offices – Mills
Division
701 E. El Camino Real Mountain View CA 94040 (408) 524-5034 PAMFROIDept@sutterhealth.org
Palo Alto Medical Foundation (PAMF) Clinics/Doctor’s Offices – Palo Alto
& Alameda Divisions
795 El Camino Real Palo Alto CA 94301 (650) 838-1606 PAMFROIDept@sutterhealth.org
Palo Alto Medical Foundation (PAMF) Clinics/Doctor’s Offices – Santa
Cruz Division
2880 Soquel Ave. Ste. 1 Santa Cruz CA 95062 (831) 479-6636 PAMFSZROIDept@sutterhealth.org
San Mateo Hand Therapy Clinic, San Mateo 101 N. El Camino Real #1 San Mateo CA 94401 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Amador Hospital, Jackson 200 Mission Blvd. Jackson CA 95642 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Auburn Faith Hospital, Auburn 11815 Education St. Auburn CA 95602 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Care At Home (SCAH) / Sutter Visiting Nurses Association & Hospice
(SVNAH), Various
Various Various CA -- (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Center for Psychiatry, Sacramento 7700 Folsom Blvd. Sacramento CA 95826 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Coast Clinics/Doctor’s Offices, Crescent City 780 East Washington Blvd. Ste. 202 Crescent City CA 95531 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Coast Health Center, Brookings OR 555 5th St. Ste. 2 Brookings OR 97415 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Coast Hospital, Crescent City 800 East Washington Blvd. Crescent City CA 95531 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Davis Hospital, Davis 2000 Sutter Place Davis CA 95616 (916) 736-5499
S3ROIDept@sutterhealth.org
Revised 9/8/2020
Sutter Health Facility Listing (Hospitals and Clinics/Foundations) for Requesting Medical Record Copies
Facility Name Mailing Address City State Zip Fax Email
Sutter Delta Medical Center, Antioch 3901 Lone Tree Way Antioch CA 94509 (925) 779-3009
sdmc-
himreleaseofinformation@sutterhealth.org
Sutter East Bay Medical Foundation (SEBMF) Clinics/Doctor’s Offices,
Albany/Antioch/Berkeley/Brentwood/Castro Valley
2320 Woosley St. Ste. 301 Berkeley CA 94705 (510) 549-9319 ebroidept@sutterhealth.org
Sutter Gould Medical Foundation (SGMF) Clinics/Doctor’s Offices –
Modesto
600 Coffee Rd. Modesto CA 95350 (209) 526-7146 SGMFROI@sutterhealth.org
Sutter Gould Medical Foundation (SGMF) Clinics/Doctor’s Offices –
Stockton
2505 W. Hammer Lane Stockton CA 95209 (209) 473-9388 SGMFROI@sutterhealth.org
Sutter Lakeside Clinics/Doctor’s Offices, Lakeport 5196 Hill Road East Ste. 300 Lakeport CA 95453 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Lakeside Hospital, Lakeport 5176 Hill Road East Lakeport CA 95463 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Maternity & Surgery Center Santa Cruz, Santa Cruz 2900 Chanticleer Ave. Santa Cruz CA 95065 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Medical Center Sacramento (Sutter General/Memorial Hospital),
Sacramento
2825 Capitol Ave. Sacramento CA 95816 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Medical Foundation (SMF) Clinics/Doctor’s Offices, Davis/West
Sacramento/Winters/Woodland
1014 N. Market Blvd #20 Sacramento CA 95834 (855) 421-9633 SMFROIDept@sutterhealth.org
Sutter Medical Foundation (SMF) Clinics/Doctor’s Offices, Citrus
Heights/Elk Grove/Folsom/Rancho Cordova/Sacramento
1014 N. Market Blvd #20 Sacramento CA 95834 (855) 421-9633 SMFROIDept@sutterhealth.org
Sutter North Medical Foundation (SNMF) Clinics/Doctor’s Offices, Yuba
City
1014 N. Market Blvd #20 Sacramento CA 95834 (855) 421-9633 SMFROIDept@sutterhealth.org
Sutter Pacific Medical Foundation (SPMF) Clinics/Doctor’s Offices,
Healdsburg/Novato/Petaluma/Rohnert Park/San Francisco/Santa Rosa
3883 Airway Dr. Ste. 320 Santa Rosa CA 95403 (707) 573-5407 spmfhimsr@sutterhealth.org
Sutter Roseville Medical Center, Roseville One Medical Plaza Roseville CA 95661 (916) 736-5499
S3ROIDept@sutterhealth.org
Sutter Santa Rosa Infusion Center, Santa Rosa 30 Mark West Springs Rd. Santa Rosa CA 95404 (707) 541-9107
S3ROIDept@sutterhealth.org
Sutter Santa Rosa Bariatric Clinic, Santa Rosa 4729A Hoen Ave Santa Rosa CA 95405 (707) 541-9107
S3ROIDept@sutterhealth.org
Sutter Santa Rosa Regional Hospital, Santa Rosa 30 Mark West Springs Rd. Santa Rosa CA 95404 (707) 541-9107
S3ROIDept@sutterhealth.org
Sutter Solano Medical Center, Vallejo 300 Hospital Dr. Vallejo CA 94589 (707) 554-5110
S3ROIDept@sutterhealth.org
Sutter Solano Medical Foundation (SSMF) Clinics/Doctor’s Offices,
Dixon/Fairfield/Vacaville/Vallejo
1014 N. Market Blvd #20 Sacramento CA 95834 (855) 421-9633 SMFROIDept@sutterhealth.org
Sutter Tracy Community Hospital, Tracy 1420 N. Tracy Blvd. Tracy CA 95376 (916) 736-5499 S3ROIDept@sutterhealth.org
Sutter Walk-In Care Clinics – Bay Area,
Aptos/Concord/Dublin/Milpitas/Mountain
View/Novato/Oakland/Petaluma/San Francisco/San Jose/San
Ramon/Santa Clara/Santa Rosa/Walnut Creek
Various Various CA -- -- PAMFROIDept@sutterhealth.org
Sutter Walk-Care Clinics – Valley Area,
Citrus Heights/Davis/El Dorado Hills/Elk Grove/Folsom/Rancho
Cordova/Roseville/Sacramento/West Sacramento
Various Various CA -- -- SMFROIDept@sutterhealth.org
Transplant Outreach Clinics, Multiple Locations 3883 Airway Dr. Ste. 320 Santa Rosa CA 95403 (707) 573-5407 spmfhimsr@sutterhealth.org
Revised 9/8/2020
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 2020: Medical Record Authorization Form Instructions How

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document