Request Medical Records
These forms are for Dartmouth-Hitchcock patients at all locations.
To request that copies of your medical record be sent FROM Dartmouth-Hitchcock
- Please fill out our Authorization for Disclosure form (PDF) and mail or return it to Dartmouth-Hitchcock.
To request that your medical record be sent TO Dartmouth-Hitchcock from another healthcare provider or facility
- Please fill out a Request for Medical Record form.
To designate others to view and manage your medical records
- Fill out our Designation of Personal Representative Form (PDF) and mail or return it to Dartmouth-Hitchcock. This designation expires one year from the date signed, and must be renewed in writing every year.
To request changes to your medical records
- Fill out our Request for Amendment of Protected Health Information Form (PDF) and mail or return it to Dartmouth-Hitchcock.
- To protect the confidentiality of our patients, we can only fax medical records in extreme emergencies.
Contact us if you have any questions.