Request for Medical Records
Download our authorization to disclose protected health information form.
To request copies of your medical record for your own use or to disclose to health care providers, insurance companies, attorneys or other third parties, you must:
- Make your request in writing by completing our authorization to disclose protected health information form.
- For additional information contact Concord Hospital Health Information Management Services at (603) 228-7312 or e-mail firstname.lastname@example.org.
We may utilize a trusted business associate to fulfill your request in compliance with state and federal regulations. There will be a fee associated with fulfilling your request. Per NH State Law RSA 332-I: 1, the fee shall not exceed $15.00 for the first 30 pages or $0.50 per page, whichever is greater.
Concord Hospital Medical Group patients have secure, online access to their health information using Patient Connect where they may request free, electronic copies of the following documentation for up to three years:
- Office visit information;
- Laboratory results;
- Radiology results;
- Cardiology results.
Completing the Authorization Form
To complete either the paper authorization to disclose protected health information or to submit the electronic request via Patient Connect:
Check the “purpose” as “Personal Records;”
For records to be sent to another person or organization: complete “Send/Disclose” information;
The name and address and phone # of the person or organization to send the records to;
Complete the “purpose;”
Complete the “type of info requested;"
Complete “Dates of care to be released.” (You may not request future dates.);
Certain types of sensitive information may be specifically excluded by initialing the type;
Complete the authorization expiration date if different than six months from signature date;
- Sign and date the form.
How We Use Your Health Information
We primarily use electronic medical record systems to capture medical information in both the inpatient and outpatient settings. These systems allow your information to be available to:
- Your healthcare providers and staff at Concord Hospital;
- Concord Hospital Medical Group Practices;
- Other providers who are involved in your care such as:
- Primary care providers;
- Specialty care providers;
- Consulting providers;
- On-call providers;
- Emergency/urgent care providers;
- Hospitalists and other hospital-based providers;
You do not need to complete an authorization form for these providers to access the health information in your EMR related to your medical treatment.
Frequently Asked Questions
Do you provide copies of birth certificates?
No. The Concord City Clerk's Office provides certified copies of birth records to immediate family members for births that occurred in Concord, NH prior to 1989, as well as for births that occurred in any city or town in the State of New Hampshire after 1988.
I am an adoptee seeking information about my birth parents, who do I call for this information?
Call the New Hampshire Health and Human Services Department at (603) 271-4702.
What happens to my information after it is released?
You can ask the receiver of this information how it is used and stored.
How much information do you send for each request?
We limit the information sent to the minimum necessary for the purpose stated in the request. You may specify on the request form that specific information not be disclosed.
Can I obtain a copy of medical records other than my own?
Generally, you may not. There are some exceptions. You will need to provide written documentation to verify any of the exceptions:
- If you have written authorization from the patient.
- If you are the patient's legal guardian.
- If you have been appointed by the patient as their legal representative.
- If the patient is under 18 and you are the parent or legal guardian.
How can I obtain copies of my medical records related to services provided by my physician at his/her office?
Please call the physician office and ask about their process for releasing your medical records. If the practice is owned by Concord Hospital, you will be able to use the Concord Hospital Authorization To Disclose Protected Health Information form.