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Get Sutter Health Authorization Form

L law. Please complete all fields and print legibly to ensure timely processing. Patient Name (Under age 12) Last Phone First SSN MI DOB Last 4 digits only I grant authorization to the following individual to access the health information in My Health Online, for the patient named above: Stepparent Street Address City Phone State Zip Code DOB SSN Last 4 digits only E-mail Address Natural Parent or Guardian Street Address City Phone State Zip Code DOB SSN Last 4 digits only E-mail Ad.

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