Medical Records & Release Forms
Dartmouth-Hitchcock keeps a private, secure medical record about your health.
- Review the information in your medical records.
- Request a copy of your medical records. This often involves a fee.
- Request that your medical records be released to someone else.
We take every precaution to keep these records secure and in order. Our Notice of Privacy Practices (PDF) explains the ways we may use or disclose (release) your medical records.
Contact us if you have any questions.
Note: To protect the confidentiality of our patients, we can only fax medical records in extreme emergencies. Please plan ahead to leave enough time for records to be mailed.
The forms on this page are for Dartmouth-Hitchcock patients at all locations.
To Have Copies of Your Medical Record Sent FROM Dartmouth-Hitchcock to Someone Else
- To have your records sent to another healthcare provider or facility, please fill out our Authorization for Disclosure Form (PDF) and mail or return it to Dartmouth-Hitchcock. Click here for detailed instructions on how to use the form.
To Have Your Medical Record Sent TO Dartmouth-Hitchcock
To have your records sent to Dartmouth-Hitchcock from another provider or facility, please fill out our Incoming Authorization Form (PDF) and give to the provider or facility who will be sending the record. Click here for detailed instructions on how to use the form. Please note that the sending health care provider’s office may have additional requirements for authorizing records to be released to Dartmouth-Hitchcock.
To Authorize Others to View and Manage Your Medical Records
- Fill out our Designation of Personal Representative Form (PDF) and mail or return it to Dartmouth-Hitchcock.
To Request Changes to Your Medical Records
- Fill out our Request for Amendment of Protected Health Information Form (PDF) and mail or return it to Dartmouth-Hitchcock.
To Consent to Medical Treatment of a Minor Child
- Fill out our Authorization to Consent to Medical Treatment of Minor Child Form (PDF) and mail or return it to Dartmouth-Hitchcock.
Manage Your Health Care with myD-H!
Communicate securely with your health care providers, request or change appointments, request prescription renewals, view your account and make payments online, review your medical record, and more. Learn more about myD-H.