Dartmouth Health medical records and release forms
The forms on this page are for patients at all Dartmouth Health member locations except for:
We keep a private, secure medical record about your health.
You can:
- Review the information in your medical records using myDH.
- Request a copy of your medical records using myDH.
- Have your medical records sent to us.
- Authorize others to view and manage your medical records.
- Revoke permission for others to view or share your medical records.
- Request changes to your medical records.
- Request a copy of a decedent's medical record or autopsy report.
- Have copies of your medical record sent from us 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.
Have your medical records sent TO us
To have your records sent to us from another provider or facility, please fill out the Permission to Send Health Information to Dartmouth Health form and give it to the provider or facility who will be sending the record.
Please note: The sending healthcare provider's office may have additional requirements for authorizing records to be released to Dartmouth Health.
Forms and instructions
Authorize others to view and manage your medical records
To authorize others to view and manage your medical records, please fill out the Designation of Personal Representative form and mail or return it to us.
Forms
Revoke permission for others to view or share your medical records
To revoke permission for others to view or share your medical records, please fill out the Revocation of Protected Health Information (PHI) form and mail or return it to us.
Forms
Request changes to your medical records
To request a change to your medical records, please fill out the Request for Amendment of Protected Health Information (PHI) form and mail or return it to us.
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.
Forms
For the surviving spouse or next of kin, please fill out the forms below:
- Dartmouth Health Affiliated Covered Entity Permission to Share Protected Health Information (PHI) (PDF)
- Decedent Surviving Spouse/Next of Kin Affidavit (PDF) along with a copy of the death certificate
For the Administrator or Executor of the decedent's estate, please fill out the form below and mail or return it to us along with proof of appointment from a probate court.
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 Permission to Share Protected Health Information form and mail or return it to us.