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Sutter imaging referral form pdf 2026

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Click ‘Get Form’ to open the Sutter Imaging Referral Form in our platform.
Begin by entering the patient's name, date of birth (DOB), and Social Security Number (SSN) in the designated fields. Ensure accuracy for proper identification.
Fill in the referring physician's details, including their name, address, and contact information. This section is crucial for communication regarding the referral.
Indicate whether your office has access to SutterLink/Sutter EHR by selecting 'Yes' or 'No'. This helps streamline the referral process.
Complete the insurance section by providing the insurance company name, phone number, authorization number, and person authorizing. If applicable, specify any conditions covered by CCS.
Select the specialty requested from the list provided (e.g., Cardiology, Orthopedics). You can choose either Adult or Pediatric specialties as needed.
Lastly, provide a brief diagnosis and clinical history in the respective fields to give context for the referral.
Once completed, you can easily save or send your form directly from our editor. Make sure to fax it to Sutter Specialty Network at (916) 503-7632 as instructed.

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