Requesting a Run Report
Federal law strictly limits who may obtain your confidential patient care report.
Patients and Patient Representatives
If you wish to request your patient care report, please download, sign and fax or mail us this form. Please note the form must be signed by the patient unless the patient is not capable of signing or is deceased.
When a patient is not capable of signing on his/her own behalf, the form may be signed by his/her legal guardian or durable power of attorney for all legal matters. A valid NH Durable Power of Attorney for Health Care does permit the patient’s representative to request any and all Personal Health Information including a patient care report. Documentation must be included with the request verifying the representative's status.
In the case of a deceased patient, a separate form must be used.
Private attorneys seeking patient run reports in conjunction with litigation must submit the form signed by the patient. A letter from an attorney or paralegal is insufficient. The fee for obtaining a patient care report is $15.
To download a copy of our patient privacy practices, click here.