Get Sutter Health Form Sh-0122 2019-2025
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How to fill out the Sutter Health Form SH-0122 online
Filling out the Sutter Health Form SH-0122 online is a straightforward process designed to help you request radiology images efficiently. This guide provides clear instructions for each section of the form, ensuring you can complete it accurately and with ease.
Follow the steps to fill out the Sutter Health Form SH-0122 online.
- Click ‘Get Form’ button to obtain the form and open it in your chosen digital editor.
- Enter patient information: Fill in the patient's first and last name, middle initial (if applicable), full address, date of birth, phone number including area code, and email address (required for contact purposes).
- Indicate the Sutter Health location releasing images: Write the specific name of the Sutter Health location where the images were obtained, using the attached listing for reference.
- Select the delivery method for your images: You have three options: check the box to send images by mail and provide the name and address; check the box if you will pick them up yourself; or check the box to authorize another person to pick them up on your behalf, including their name.
- Specify which images you would like released: Check the appropriate type(s) of images requested (CT Scan, MRI, X-ray, Ultrasound, Mammography, or Other). If 'Other' is selected, please specify the exam type.
- State the purpose of disclosure: Indicate the reason you need the records, such as personal use, transfer of care, second opinion, or seeing a specialist, as this is required by law.
- Set an expiration date for the authorization (optional): The default is one year from the date signed, unless you specify a different date at least 15 days in the future.
- Provide a signature and date: Sign and date the form to validate the authorization. If you are signing on behalf of the patient, print your name and relationship.
- If signed by someone other than the patient: Print the name and relationship of the person signing, and include any necessary legal documentation (e.g., Power of Attorney).
- Finalize the process: Once all fields are completed, save changes, download, print, or share the form as needed.
Complete your documents online to streamline your radiology image request process.
The lawsuit against Sutter Health pertains to various claims, including patient care and operational practices. For accurate and updated information regarding the lawsuit, reviewing public records and legal documents can be helpful. If you have specific concerns or need to report incidents, you may need to fill out forms like the Sutter Health Form SH-0122 to provide the necessary information. Staying informed about these matters is important for all stakeholders.
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