authorization to release

Form 8/3/11 Rev. 7/15/13 Rev. 8/30/13 Instructions: 1. Please complete this entire record. 2. Please allow 7‐10 days for New Hampshire NeuroSpine Institute to process your request 3. In accordance with our policy, if you are releasing records to yourself, they will be mailed to you in 7‐10 business days. Records will not be available for pick up in any of our offices. 4. Pursuant to New Hampshire State Law Chapter 332‐I section 332‐I: 1 you will be charged a reasonable fee for your medical records. Please be sure to provide an email or a fax number to receive your invoice this will help to avoid any delay in sending out your records. 5. As a courtesy we will forward a copy of your records to a medical provider’s office at no charge. I hereby authorize the disclosure of information from health records of: Patient name: Patient DOB: Office use only: MR# Street Addresss City, State and Zip Primary Telephone Alternate # or fax# T(603)472-8888 F(844)504-9181 Please indicate if there is a date range: __________________________ Please indicate if you prefer an electronic copy of your request *** An email is required for electronic records requests, email: _______________________________________________ I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, otherwise restrict my ability to authorize the use or disclosure of this protected health information. _________________________________________________________ ______________________ Signature of patient or authorized representative Date _________________________________________________________ Printed name of patient or representative ______________________ Date Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis, drug/ alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information. For office use only: Patient requesting records Initials: __________ Date: __________ Fee obtained Amount: __________ Method: __________ Authorization to Release Medical Records I give permission to disclose my protected health information verbally to: Name______________________________________Relationship________________ If Additional please indicate another here: Name________________________________ Relationship______________ Method of disclosure: Release records from New Hampshire NeuroSpine Institute to: Name: ________________________________________________________________________________________ Address: _____________________________________________________________________________________ Telephone: _____________________________ Fax: ________________________________________________ Release records to New Hampshire NeuroSpine Institute from: Rev. 4/2/19 Email: (circle one) Rev. 3/9/20 Name: ________________________________________________________________________________________ Address: _______________________________________________________________________________ Telephone: _________________________ Fax: ___________________________ Please send records to the main office: 4 Hawthorne Drive, Bedford, NH 03110 Information to disclose: Progress notes Hospital/Op notes Lab/Xray reports Testing on CD Telephone Message/Chart notes Correspondence All Records Other: _________________

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Form 8/3/11

Rev. 7/15/13 Rev. 8/30/13

Instructions: 1. Pleasecompletethisentirerecord.2. Pleaseallow7‐10daysforNewHampshireNeuroSpineInstitutetoprocessyourrequest3. Inaccordancewithourpolicy,ifyouarereleasingrecordstoyourself,theywillbemailedtoyouin7‐10

businessdays.Recordswillnotbeavailableforpickupinanyofouroffices.4. PursuanttoNewHampshireStateLawChapter332‐Isection332‐I:1youwillbechargeda reasonable fee

for your medical records. Please be sure to provide an email or a fax number to receive your invoice this will help to avoid any delay in sending out your records.

5. Asacourtesywewillforwardacopyofyourrecordstoamedicalprovider’sofficeatnocharge.

Iherebyauthorizethedisclosureofinformationfromhealthrecordsof:Patientname: PatientDOB: Officeuseonly:

MR#StreetAddresss City,StateandZip

PrimaryTelephone Alternate# or fax#

T(603)472-8888F(844)504-9181

Pleaseindicateifthereisadaterange:__________________________Pleaseindicateifyoupreferanelectroniccopyofyourrequest *** An email is required for electronic records requests, email: _______________________________________________

Iunderstandthatafterthecustodianofrecordsdisclosesmyhealthinformation,itmaynolongerbeprotectedbyfederalprivacylaws.IfurtherunderstandthatthisauthorizationisvoluntaryandthatImayrefusetosignthisauthorization.Myrefusaltosignwillnotaffectmyabilitytoobtaintreatment;receivepayment;oreligibilityforbenefitsunlessallowedbylaw.BysigningbelowIrepresentandwarrantthatIhaveauthoritytosignthisdocumentandauthorizetheuseordisclosureofprotectedhealthinformationandthattherearenoclaimsororderspendingorineffectthatwouldprohibit,limit,otherwiserestrictmyabilitytoauthorizetheuseordisclosureofthisprotectedhealthinformation.

_________________________________________________________ ______________________Signatureofpatientorauthorizedrepresentative Date_________________________________________________________Printednameofpatientorrepresentative

______________________Date

Note:IftheserecordscontainanyinformationfrompreviousprovidersorinformationaboutHIV/AIDSstatus,cancerdiagnosis,drug/alcoholabuse,orsexuallytransmitteddisease,youareherebyauthorizingdisclosureofthisinformation.

Forofficeuseonly: PatientrequestingrecordsInitials:__________Date:__________FeeobtainedAmount:__________Method:__________

AuthorizationtoReleaseMedicalRecords

I give permission to disclose my protected health information verbally to: Name______________________________________Relationship________________ If Additional please indicate another here: Name________________________________ Relationship______________

Methodofdisclosure:ReleaserecordsfromNewHampshireNeuroSpineInstituteto:

Name:________________________________________________________________________________________Address:_____________________________________________________________________________________Telephone: _____________________________Fax:________________________________________________

ReleaserecordstoNewHampshireNeuroSpineInstitutefrom:

Rev. 4/2/19

Email: (circle one)

Rev. 3/9/20

Name:________________________________________________________________________________________Address:_______________________________________________________________________________Telephone: _________________________ Fax: ___________________________Pleasesendrecordstothemainoffice:4HawthorneDrive,Bedford,NH03110

Informationtodisclose:Progressnotes Hospital/OpnotesLab/Xrayreports

Testing on CD TelephoneMessage/ChartnotesCorrespondenceAllRecords Other: _________________

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