Request for Medical Records
To request copies of your medical record for your own use, you must make your request in writing. When we receive your request we will then require an Authorization to Disclose Protected Health Information" to be completed and signed by you in order to process your request. Please indicate with your request if you would like this form mailed to you for completion or if you would like to come in to our office and complete it.
Please mail your request to:
Center for Life Management
10 Tsienneto Road
Derry, NH 03038
Attn: Medical Records
There will be a fee associated with fulfilling your request. This procedure abides by the state law requirements for New Hampshire (New Hampshire Title XXX, chapter 332-I, Section 332_i:1).
If you have not requested your records before:
- 1st 25 pages = free
- Additional pages = $0.25 per page
If you have requested your records before:
- $0.25 per page
There is no charge for releasing copies of health information directly to other healthcare providers.
Processing Your Request
Please allow 7 to 10 business days to complete your request. Certain circumstances may require more time. You will receive a phone call when your records are ready to be picked up. Please be prepared to show your photo id when picking up your records.
For further information regarding requests for medical records please call (603) 434-1577 and ask for the medical records department.