Radiology Images Request Form Instructions
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How to Complete the Radiology Images Authorization Form
Please download and save a copy of this form to your computer before filling it out.
Patient Information
o Enter the patient’s First and Last Name, Middle Initial (if any), full address, date of birth, phone number including
area code, and patient’s email address (required for contact purposes)
Sutter Health Location Releasing Images
o Enter the name of the specific Sutter Health location where images were taken. Use the attached listing to locate
the correct Imaging Center.
How Would You Like Your Images Delivered? (Note: Images are produced on CD only).
o Send them by mail to
: Check this box if you want the imaging records mailed to you. Include the full name and address where
we can mail the records.
o I will pick them up myself.
Check this box if you want to pick up the records in person. The Imaging Department will notify you when
the CD is ready for pickup.
o I authorize the following person to pick them up for me (first and last name).
Check this box and provide us the name of the person you authorize to pick up the CD on your behalf.
What Would You Like released?
o Check the appropriate type(s) of images you are requesting (CT Scan, MRI, X-ray, Ultrasound, Mammography,
Other). Check all that apply. If “Other” is selected, please type in the exam type name.
Purpose of Disclosure
o Tell us why you need the records. (Required by law.)
Expiration Date (Optional). The authorization will be effective for one year from the date you sign it, unless revoked by
you. You have the right to give us an alternative expiration date. If you do, it must be dated at least 15 days in the future
from the date you sign the authorization to allow ample time to process your request as permitted by California law.
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. This section also
explains your rights under the law.
If signed by other than the patient, print name and relationship. If you are completing this authorization on behalf of
the patient, list your name and your relationship to the patient. You will be asked to provide supporting documentation that
gives you the legal authority to request records on behalf of the patient. Supporting documentation may include: Death
Certificate, Executor of the Estate (for deceased patients), 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).
If you need additional help with completing the Authorization Form, call the phone number on the attached
listing for the Imaging Center where you had your images taken.
