Consent to Release Medical Records

Patient Information

Patient's Full Name*

Email Address

Street Address

City

State

Zip Code

Phone Number

Date of Birth

I hereby authorize New Hampshire Orthopaedic Center to release the following records (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 or fax only.)

Nam*

Organization*

Address*

City*

State*

Zip*

Phone*

Fax

The purpose of the release of my medical record is:*

Signature

Patient Information

Person or organization to whom the information is being released (Records can NOT be picked up. Mail or fax only.)

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