Tracking Form for Disclosure of Protected Health Information 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the Patient Information section. Enter the patient's name, date of birth (DOB), medical record number (MRN), address, city, state, zip code, phone number, and email (optional).
3. In the Type of Access Requested section, select only one option that suits your needs: Paper Copy, CD, My Health Online, Inspection Only, Email (encrypted), Email (not encrypted), or Other.
4. Next, choose a Delivery Method by checking one box: Mail, Email, Fax, Pick-Up (if applicable), or My Health Online Portal.
5. Specify the Purpose of Requested Use or Disclosure by selecting how you will use the records. This is a legal requirement.
6. In the Authorization section, select your Sutter care facility from the dropdown menu or manually enter it from the attached list.
7. Indicate to whom you want your health information released. If it's for yourself, check the corresponding box.
8. Fill out the Information Disclosure section by specifying what information you need and for which date range.
9. Complete Page 2 by providing any Special Authorization needed for sensitive information and entering an expiration date if desired.
10. Finally, sign and date the form as required by law. Ensure all fields are completed before submitting.

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