Sutter Health Form SH-0009 2013 free printable template

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION Patient Name: DOB: MAN: Address: City: State: Zip: Phone: Email (optional): Type of Access Requested: Paper Copy CD Inspection Only Email

How to fill out Sutter Health Form SH-0009

How to fill out Sutter Health Form SH-0009

1. Begin with the patient's personal information: Enter the full name, date of birth, and contact details in the designated sections.
2. Fill in the insurance information: Include the insurance provider's name, policy number, and coverage details.
3. Provide medical history: Answer all questions related to previous medical conditions, surgeries, and current medications.
4. Complete the consent section: Read the consent statements carefully and provide a signature and date.
5. Review the form: Ensure all sections are filled out correctly and that the information is accurate.
6. Submit the form: Send the completed form to the appropriate Sutter Health office as indicated in the instructions.

Who needs Sutter Health Form SH-0009?

1. Patients seeking medical services at Sutter Health facilities may need this form to provide essential information for their care.
2. Insurance providers may require this form to process claims related to services received by the patient.

People Also Ask about

What is a log of disclosure of PHI?

$47.25. As required by HIPAA, you must track to whom disclosures of PHI are made. This form, retained in each patient's medical record, includes the pertinent information that should be recorded when disclosures are made.

Which of the following disclosures have to be tracked for the accounting of disclosures requirement?

Disclosures that Commonly Qualify for Accounting An accounting is required if the disclosure is made and no authorization from the patient or patient's personal representative is obtained: In response to a subpoena or other judicial or administrative proceeding if not accompanied by a patient authorization.

What form is used to disclose PHI?

A HIPAA authorization form, also known as a HIPAA release form, is a document that individual signs for their health provider before the entity may use or disclose their protected health information (PHI).

How long must a disclosure of PHI for TPO be tracked?

The HIPAA Privacy Rule gives a person the right to request a written record (“an accounting”) when a covered entity has made certain disclosures of that person's protected health information (“PHI”). The accounting must include all covered disclosures in the six years prior to the date of the person's request.

Which document must be obtained and signed in order to disclose protected health information?

A Privacy Rule Authorization is an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.

For pdfFiller’s FAQs

How can I edit Sutter Health Form SH-0009 on a smartphone?

The pdfFiller apps for iOS and Android smartphones are available in the Apple Store and Google Play Store. You may also get the program at https://edit-pdf-ios-android.pdffiller.com/. Open the web app, sign in, and start editing Sutter Health Form SH-0009.

How do I complete Sutter Health Form SH-0009 on an iOS device?

Install the pdfFiller app on your iOS device to fill out papers. If you have a subscription to the service, create an account or log in to an existing one. After completing the registration process, upload your Sutter Health Form SH-0009. You may now use pdfFiller's advanced features, such as adding fillable fields and eSigning documents, and accessing them from any device, wherever you are.

Can I edit Sutter Health Form SH-0009 on an Android device?

You can edit, sign, and distribute Sutter Health Form SH-0009 on your mobile device from anywhere using the pdfFiller mobile app for Android; all you need is an internet connection. Download the app and begin streamlining your document workflow from anywhere.

What is Sutter Health Form SH-0009?

Sutter Health Form SH-0009 is a document used by Sutter Health to collect and report specific health-related information necessary for compliance and operational purposes.

Who is required to file Sutter Health Form SH-0009?

Individuals, healthcare providers, and organizations involved with Sutter Health services who meet certain criteria and are required to report specific health data.

How to fill out Sutter Health Form SH-0009?

To fill out Sutter Health Form SH-0009, carefully follow the instructions provided with the form, ensuring to provide accurate information and any necessary documentation as specified.

What is the purpose of Sutter Health Form SH-0009?

The purpose of Sutter Health Form SH-0009 is to ensure the accurate collection of health data that can be used for analysis, compliance, and improving health services provided by Sutter Health.

What information must be reported on Sutter Health Form SH-0009?

Information that must be reported on Sutter Health Form SH-0009 includes patient identifiers, health conditions, treatment details, and any other data as required by Sutter Health guidelines.