• Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Who do you wish to release your records to?

  • Who do you wish to obtain your records from?

  • Authorization and Signature:

    I hereby authorize NHTI Concord’s Community College Health Services Staff to release the records as above. This authorization is valid for one (1) year and may be revoked (except retroactively) at any time in writing prior to the expiration date. I do not give permission for any other use or re-release of this information.

    I release NHTI Health Services from all legal responsibility or liability that may arise from the act I have authorized above.

  • Date Format: MM slash DD slash YYYY
  • Release of Protective Health Information

  • IF INFORMATION TO BE RELEASED INCLUDES ANY OF THE INFORMATION DESCRIBED BELOW, you must initial those that apply below:
  • I hereby authorize NHTI Health Service Staff to release all information in such records as initialed above.
  • Date Format: MM slash DD slash YYYY
$0
Application Fee