Medical Records & Release Forms

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

You can:

• 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 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 Hitchcock Medical Center and Clinics locations.

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.

• Permission to Share Protected Health Information form (PDF)
• (Spanish version - PDF)

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

To have your medical record sent TO us

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

• Permission to Send Health Information to Dartmouth Hitchcock Medical Center and Clinics Affiliated Covered Entity form (PDF)
• (Spanish version - PDF)

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

Please note that the sending health care provider's office may have additional requirements for authorizing records to be released to Dartmouth Hitchcock Medical Center and Clinics.

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:

• Designation of Personal Representative Form (PDF)
• Spanish version (PDF)
• Designation of Personal Representative for Minor (PDF)

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:

• Revocation of Authorized Disclosure of PHI Form (PDF)

To request changes to your medical records

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

• Request for Amendment of Protected Health Information Form (PDF)

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:

• If you are the Administrator or Executor of the decedent's estate, please fill out the following form and mail or return it to us along with proof of appointment from a probate court.
  • Permission to Share Protected Health Information form (PDF)
  • (Spanish version - PDF)
• If you are the surviving spouse or next of kin, please fill out the following form:
  • Permission to Share Protected Health Information form (PDF)
  • (Spanish version - PDF)
• Also, complete the Decedent Surviving Spouse/Next of Kin Affidavit (PDF), and mail or return them to us along with a copy of the death certificate.