AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION
*Authorization – I hereby authorize:
Radiology Image Disclosure (Tell us what images you need)
Radiology Image Disclosure (Tell us what images you need)
 
*Purpose of Requested Use or Disclosure (Tell us how you will use the records)
*Purpose of Requested Use or Disclosure (Tell us how you will use the records)
 
To release my health information to: (if the recipient is not the patient listed above)
To release my health information to: (if the recipient is not the patient listed above)
*Enter the visit date range for the records being requested above. Do not enter dates in the future.
*Enter the visit date range for the records being requested above. Do not enter dates in the future.
Please contact Medical Foundation Billing Information
Monday through Friday, 7:00 am — 7:00 pm PST
  • Sutter Gould Medical Foundation — (866) 681-0735
  • Sutter Medical Foundation — (866) 681-0736
  • Sutter Pacific Medical Foundation — (866) 681-0739
  • Sutter East Bay Medical Foundation — (866) 681-0745
  • Palo Alto Medical Foundation — (877) 252-1777
Special Authorization (Tell us if we have permission to release the following sensitive information)I specifically authorize release of the following information:
Special Authorization (Tell us if we have permission to release the following sensitive information)

I specifically authorize release of the following information:

ExpirationThis authorization shall become effective immediately and shall remain in effect for one (1) year from the date signed unless otherwise specified below.
Expiration
This authorization shall become effective immediately and shall remain in effect for one (1) year from the date signed unless otherwise specified below.
Restrictions
California law prohibits the recipient 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.
Your Rights
  • 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 delivered to this address:

    For Sutter Hospitals:
    Sutter Shared Services
    Attn: HIM Director
    P.O. Box 619091
    Roseville, CA 95661
    Palo Alto
    Medical Foundation
    Attn: HIM Director
    795 El Camino Real
    Palo Alto, CA 94301
    Sutter East Bay
    Medical Foundation
    Attn: HIM Director
    3687 Mt Diablo Blvd. #200
    Lafayette, CA 94549
    Sutter Gould
    Medical Foundation
    Attn: HIM Director
    600 Coffee Road
    Modesto, CA 95350
    Sutter Pacific
    Medical Foundation
    Attn: HIM Director
    3883 Airway Dr. Suite 320
    Santa Rosa, CA 95403
    Sutter Medical
    Foundation
    Attn: HIM Director
    1014 N. Market Blvd. #10
    Sacramento, CA 95834


  • My revocation will be effective upon receipt, but will have no impact on uses or disclosure made while my authorization was valid.
  • I have a right to receive a copy of this authorization (required if authorization is requested for the provider’s use or disclosure of health information).
  • I may inspect and obtain a copy of the health information of which I am authorizing the use or disclosure of my health information.

Compensation
Compensation
If signed by other than the patient, print name and relationship:
If signed by other than the patient, print name and relationship:
Please upload supporting documentation that authorizes you to receive information on behalf of the patient (i.e., Death Certificate, Power of Attorney for healthcare, Court Order, etc.)
Please upload supporting documentation that authorizes you to receive information on behalf of the patient (i.e., Death Certificate, Power of Attorney for healthcare, Court Order, etc.)
 
Choose file