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.
Tel: (603) 271-6484(800) 247-0179 email@example.com
NHTIConcord’s Community College31 College DriveConcord, NH 03301