Form 8/3/11

Rev. 7/15/13 Rev. 8/30/13 

Instructions: 1. Pleasecompletethisentirerecord.2. Pleaseallow7‐10daysforNewHampshireNeuroSpineInstitutetoprocessyourrequest3. Inaccordancewithourpolicy,ifyouarereleasingrecordstoyourself,theywillbemailedtoyouin7‐10

businessdays.Recordswillnotbeavailableforpickupinanyofouroffices.4. PursuanttoNewHampshireStateLawChapter332‐Isection332‐I:1youwillbechargeda reasonable fee

for your medical records. Please be sure to provide an email or a fax number to receive your invoice this will help to avoid any delay in sending out your records.

5. Asacourtesywewillforwardacopyofyourrecordstoamedicalprovider’sofficeatnocharge.

Iherebyauthorizethedisclosureofinformationfromhealthrecordsof:Patientname: PatientDOB: Officeuseonly:

MR#StreetAddresss City,StateandZip

PrimaryTelephone Alternate# or fax#

T(603)472-8888F(844)504-9181

Pleaseindicateifthereisadaterange:__________________________Pleaseindicateifyoupreferanelectroniccopyofyourrequest *** An email is required for electronic records requests, email: _______________________________________________

Iunderstandthatafterthecustodianofrecordsdisclosesmyhealthinformation,itmaynolongerbeprotectedbyfederalprivacylaws.IfurtherunderstandthatthisauthorizationisvoluntaryandthatImayrefusetosignthisauthorization.Myrefusaltosignwillnotaffectmyabilitytoobtaintreatment;receivepayment;oreligibilityforbenefitsunlessallowedbylaw.BysigningbelowIrepresentandwarrantthatIhaveauthoritytosignthisdocumentandauthorizetheuseordisclosureofprotectedhealthinformationandthattherearenoclaimsororderspendingorineffectthatwouldprohibit,limit,otherwiserestrictmyabilitytoauthorizetheuseordisclosureofthisprotectedhealthinformation.

_________________________________________________________ ______________________Signatureofpatientorauthorizedrepresentative Date_________________________________________________________Printednameofpatientorrepresentative

______________________Date

Note:IftheserecordscontainanyinformationfrompreviousprovidersorinformationaboutHIV/AIDSstatus,cancerdiagnosis,drug/alcoholabuse,orsexuallytransmitteddisease,youareherebyauthorizingdisclosureofthisinformation.

Forofficeuseonly: PatientrequestingrecordsInitials:__________Date:__________FeeobtainedAmount:__________Method:__________

AuthorizationtoReleaseMedicalRecords

I give permission to disclose my protected health information verbally to: Name______________________________________Relationship________________ If Additional please indicate another here: Name________________________________ Relationship______________

Methodofdisclosure:ReleaserecordsfromNewHampshireNeuroSpineInstituteto:

Name:________________________________________________________________________________________Address:_____________________________________________________________________________________Telephone: _____________________________Fax:________________________________________________

ReleaserecordstoNewHampshireNeuroSpineInstitutefrom:

Rev. 4/2/19

Email: (circle one)

Rev. 3/9/20

Name:________________________________________________________________________________________Address:_______________________________________________________________________________Telephone: _________________________ Fax: ___________________________Pleasesendrecordstothemainoffice:4HawthorneDrive,Bedford,NH03110

Informationtodisclose:Progressnotes Hospital/OpnotesLab/Xrayreports

Testing on CD TelephoneMessage/ChartnotesCorrespondenceAllRecords Other: _________________