Medical Records & Release Forms

The forms on this page are for patients at all Dartmouth Health member locations except for:

• Mt. Ascutney Hospital and Health Center
• Southwestern Vermont Health Care
• Valley Regional Hospital

We keep a private, secure medical record about your health.

• Review the information in your medical records using myDH.
• Request a copy of your medical records using myDH. This often involves a fee.
• 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

Have your records sent to us from another provider or facility, please fill out the following form and give it to the provider or facility who will be sending the record.

• Permission to Send Health Information to Dartmouth Health (PDF)
  • Spanish version (PDF)

  Please note that the sending healthcare provider's office may have additional requirements for authorizing records to be released to Dartmouth Health.

  Authorize others to view and manage your medical records

  Please fill out one of the following forms and mail or return it to us:

  • Designation of Personal Representative Form (PDF)
    • Spanish version (PDF)

    Revoke permission for others to view or share your medical records

    To revoke CareEverywhere consent, Designation of Personal Representative, or Permission to Share Patient Health Information, please fill out one of the following forms and mail or return it to us:

    • Revocation of Protected Health Information (PHI) (PDF)
    • Revocation of Protected Health Information (PHI) for Minor (PDF)

    Request changes to your medical records

    Please fill out the following 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.

    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.

    • Dartmouth Health Affiliated Covered Entity Permission to Share Protected Health Information (PHI) (PDF)
      • Spanish version (PDF)

      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)
        • Spanish version (PDF)

        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 following form and mail or return it to us.

        • Permission to Share Protected Health Information (PDF)
          • Spanish version (PDF)

          Manage your healthcare with myDH!

          • Communicate securely with your health care providers
          • Schedule, request, or change appointments
          • Request prescription renewals
          • View your account and make payments online
          • Review your medical record and more