Patient InformationPatient's Full Name* Email Address Street Address City State Zip Code Phone NumberDate of Birth MM slash DD slash YYYY How would you like to receive your records?* I would Like my records pushed to my Patient Portal. (Fastest) I would like my records e-mailed. I would like my records faxed. I would like my records MAILED. (Slowest) I hereby authorize New Hampshire Orthopaedic Center to release the following records to a destination of your choice by our third party service for a charge of $15 for the first 30 pages and .50 cents every page after pursuant to NH law(check relevant boxes): my entire medical record Initials*I hereby authorize New Hampshire Orthopaedic Center to release the following records (check relevant boxes): records relating to the following injury/condition only: Please specify Initials*I hereby authorize New Hampshire Orthopaedic Center to release the following records (check relevant boxes): office notes Initials*I hereby authorize New Hampshire Orthopaedic Center to release the following records (check relevant boxes): radiology reports Initials*I hereby authorize New Hampshire Orthopaedic Center to release the following records (check relevant boxes): operative notes Initials*I hereby authorize New Hampshire Orthopaedic Center to release the following records (check relevant boxes): other records: Please specify other records Initials*UNLESS CHECKED BELOW, I specifically and voluntarily authorize New Hampshire Orthopaedic Center to include in the release of records any information relating to the following issues, if applicable. My initials indicate I do not consent to the release of records relating to the following: mental health illness/diagnosis Initials*UNLESS CHECKED BELOW, I specifically and voluntarily authorize New Hampshire Orthopaedic Center to include in the release of records any information relating to the following issues, if applicable. My initials indicate I do not consent to the release of records relating to the following: alcohol/drug abuse/treatment Initials*UNLESS CHECKED BELOW, I specifically and voluntarily authorize New Hampshire Orthopaedic Center to include in the release of records any information relating to the following issues, if applicable. My initials indicate I do not consent to the release of records relating to the following: HIV/AIDS test results/diagnosis Initials*UNLESS CHECKED BELOW, I specifically and voluntarily authorize New Hampshire Orthopaedic Center to include in the release of records any information relating to the following issues, if applicable. My initials indicate I do not consent to the release of records relating to the following: communicable diseases Initials*Person or organization to whom the information is being released (Records can NOT be picked up. Mail, e-mail or fax only. If e-mailing to yourself please be sure to put your name and address here.)Nam* Organization* Address* City* State* Zip* Phone*FaxThe purpose of the release of my medical record is:* Dissatisfaction Relocation Physician Referral Other Decline to answer SignaturePost Title
