Proxy Access Form (Children Under 18)

Please correct the errors described below.
(write provider’s name)
(write hospital name)

Request for Online Access to Medical Records for a Minor Child

I hereby request that the Sutter Health affiliate provides access to the health information in My Health Online allowable by law, of the patient named below to the following individual. For stepparents, please complete the “Written Authorization for a Stepparent to Access the Medical Record of a Minor Child” form found on this website. Please complete all fields and print legibly to ensure timely processing.

(Under Age 18)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Fax to: (877) 607-6484

Mail to: Patient Services Contact Center

P.O. Box 255386

ATTN: My Health Online Proxy

Sacramento, CA 95865-5386


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