MEDICAL RECORDS RELEASE
You may request a copy of your personal medical records by submitting a completed authorization for Disclosure of Protected Health Information form to the Medical Records department. To return the completed form to Medical Records, you may choose one of the following:
- Mail: Medical Records, Alice Peck Day Memorial Hospital, 10 Alice Peck Day Drive, Lebanon, NH 03677
- Fax: (603) 443-9509
- In person: please visit Patient Access at the main hospital
- Email: email@example.com
You may designate a Personal Representative to assist you in exercising your health information rights under the New Hampshire Patients’ Bill of Rights and the Federal Privacy Rule by completing this form.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, please contact the privacy officer at (603) 448-3121 or at firstname.lastname@example.org.
This notice describes Alice Peck Day Memorial Hospital's privacy practices and that of:
- Any health care professional authorized to enter information into your chart
- All employees, staff, or other APD personnel and members of the medical staff
- Any member of a volunteer or student group that we allow to help you while you are a patient at APD
- All departments and units of the hospital system
- All entities, sites, and locations owned or administered by APD