N.H. Admin. Code § Cor 412.03 - Release of Information Form
(a)
The "Release of Information Form" (5/2019 edition) shall be completed by the
resident and shall contain:
(1) The
resident's name, ID number, and date of birth;
(2) The expiration date of the
form;
(3) The resident's signature;
and
(4) The signature of a witness
to the resident signing the form.
(b) The form shall identify:
(1) The name of person who is authorized to
review the file;
(2) The name of
the organization the person in (1) above represents; and
(3) The specific record(s) in the resident's
non-medical electronic record(s) the person shall examine and
discuss.
(c) The form
shall state specifically what records shall be reviewed.
(d) The resident shall sign the completed
form to consent to the following:
(1) "I
understand that these records are confidential and will not be released unless
I sign this Release of Information Form"; and
(2) "I further understand that this consent
to release information may be revoked in writing by me at any time".
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.