Privacy Request Form

Please use this form to submit your Consumer Rights Request to request that Sutter: provide access to your information; delete your information; not sell your information. You may fill out the form for yourself or someone else (e.g. a dependent or power of attorney).

Your protected health information (PHI) isn’t included in this request. For questions regarding how Sutter Health protects your health information, please view our Notice of Privacy Practices.

Who are you requesting this data for?

Requester Information:
- I am filling out this form for myself
- I am filling out this form for someone else

Requestee Information:

Your Information:

Your Information:

All fields are required.
Your Information: First Name:
Your Information: Last Name:
Your Information: Request Type:
Request Type:
- Access My Info
- Delete My Info
- Withdraw Consent for Minors
Your Information: Date of Birth:

Birth Month

Birth Day

Birth Year
Your Information: Email Address:
Your Information: Phone Number:
Copy requestee address Same as Requester:
- Same as Requestee
Your Information: Street Address
(Line 1)
Your Information: Street Address
(Line 2):
Your Information: City:
Your Information: State:
Your Information: Zip/Postal Code:
Penalty of Perjury:
Penalty of Perjury:
- I declare under penalty of perjury under the laws of the State of California that the foregoing information is true and correct.

Captcha:

Captcha:

Need Assistance?

Call (855) 771-4220 to submit a consumer rights request.

Call (855) 771-4220

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