Medical Records & Release Forms

We keep a private, secure medical record about your health.

You can:


We take every precaution to keep these records secure and in order. Our Notice of Privacy Practices 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 patients at all Dartmouth Health locations except for Mt. Ascutney Hospital and Health Center and Southwestern Vermont Health Care.

To have your medical records sent TO us

To have your records sent to us from another provider or facility, please fill out the following form and give it to the provider or facility who will be sending the record.

View detailed instructions on how to use the form (PDF)

Please note that the sending healthcare provider's office may have additional requirements for authorizing records to be released to Dartmouth Health.

To authorize others to view and manage your medical records

Please fill out one of the following forms and mail or return it to us:

To revoke permission for others to view or share your medical records

To revoke CareEverywhere consent, Designation of Personal Representative, or Permission to Share Patient Health Information, please fill out the following form and mail or return it to us:

To request changes to your medical records

Please fill out the following form and mail or return it to us.

To request a copy of a decedent's medical record or autopsy report

Under New Hampshire law, a decedent's medical information may be released either directly to the decedent's surviving spouse or next of kin, in certain circumstances, or by authorization from the Administrator or Executor of the decedent's estate. To request that a copy of a decedent's records or autopsy report be mailed to you:

To have copies of your medical record sent FROM us to someone else

To have your records sent to another healthcare provider or facility, please fill out the following form and mail or return it to us.

View detailed instructions on how to use the form (PDF).

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