Complete the Authorization Form (1 page) to authorize the release of individually identifiable health information (Protected Health Information) to third parties. This information includes:
- Medical Records;
- Claims, Payment and Billing Records; and
- Eligibility Determination Records.
A personal representative may also use the form to authorize the release of protected health information, however, legal documentation verifying and authorizing the authority of the personal representative must accompany the form.
The Authorization Form (1 page) can be printed, completed and returned as appropriate to a DHHS District Office, New Hampshire Hospital, Glenncliff Home for the Elderly, or other DHHS location. Or, a send the form to:
NH DHHS
Office of Improvement & Integrity
Privacy Officer
129 Pleasant St., Brown Building
Concord, NH 03301 |
