Facility records are being released from:Facility Name* Facility Address* Facility City* Facility State* Facility Zip* Facility PhoneFacility FaxPatient Info:Full Name* Date of Birth* MM slash DD slash YYYY I authorize the release of:Please add body part(s) images to be released* Initials*Medical RecordsWould you like to send records on a specific injury/condition or send records on all injuries/conditions? Specific injury/condition All injuries/conditions Injury/ConditionPlease specify the injury or condition you would like the records sent on. Please check the items you would like to release: Office Notes Initials*Please check the items you would like to release: Radiology Reports Initials*Please check the items you would like to release: Operative Notes Initials*Please check the items you would like to release: Other What other items would you like to release?* Initials*Specify the additional records you would like to include:Medical Records and/or images to be sent to: New Hampshire Orthopaedic Center17 Riverside Street, Suite 101Nashua, NH 03062 Fax # 603.864.1711Consent I give my permission for my records to be sent via mail or fax. If you do not check this box, your records will not be sent.2. If checked, I specifically authorize the release of the following: HIV status Initials* Communicable disease history Initials* Alcohol and drug history Initials* Mental Illness Initials*I understand that this information cannot be disclosed without my written consent except as otherwise specifically provided by law. I understand that by law, I need not to consent to the release of this information. However, I choose to do so willingly and voluntarily for the purpose specified above. 3. I have carefully read and understand the above statements. I hereby release this practice from all legal responsibility or liability whatsoever that may arise from the release of medical records or images (originals or copies). By signing below, I am verifying that all of the above information is CORRECT.Signature (Patient or Responsible Adult)*Relationship if other than Patient
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