Proxy Access Form (Children Under 18)

Select Your Sutter Affiliate / Hospital

Sutter Medical Foundation

Palo Alto Medical Foundation

Sutter Community Connect

(write provider’s name)

A Sutter Hospital

(write hospital name)

Sutter East Bay Medical Foundation

Sutter Pacific Medical Foundation

Sutter Gould Medical Foundation

Sutter Community Connect

(write provider’s name)

A Sutter Hospital

(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.

Patient Name: Last

(Under Age 18)

First

Phone

SSN

Date

Proxy Representative

Street Address

City

State

Zip Code

Phone

SSN

Date

Email address

Relationship to child *Legal documents may be required, e.g., marriage certificate, birth certificate, guardianship papers, power of attorney.

Parent

Guardian

Conservator

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.

Proxy Representative Signature

Date

Fax to: (877) 607-6484

Mail to: Patient Services Contact Center

P.O. Box 255386

ATTN: My Health Online Proxy

Sacramento, CA 95865-5386

SUTTER HEALTH USE ONLY

MRN

Department/Care Center

Patient ID Verified By

Physician Name

Your information will be encrypted.