Following is a list of forms you may need as a Derry Medical Center patient. If you have questions or are looking for information not listed here, please call us at 603.537.1300.
Release of Medical Records Form:
- Printable Version: Authorization Form for Use and Disclosure of Protected Health Information (PDF to print and mail OR bring in)
- Electronic Version: Authorization Form for Use and Disclosure of Protected Health Information (Submit online)
Patients of Doctors Bennett, Fitzgerald or Rosenbaum:
If you are a current patient of Dr. Bennett, Dr. Fitzgerald or Dr. Rosenbaum, and wish to continue to be a patient at their new office located at 160 S. River Road, Bedford, NH 03110, please select the link below to complete an electronic Medical Release form Release of Medical Records Form for Bedford Commons Practice patients.
Other Forms for All Patients:
- Printable Version: Personal Information/Lab Results Authorization
- Electronic Version: Personal Information/Lab Results Authorization
- Cologuard Order Requisition Form
- Notice of Patient Privacy Practices
- Patient Information and Authorization for Use of Electronic Mail
- Testing Procedure Instructions for Mammogram, Ultrasound, Stress Testing (ETT) and Echocardiography
- Release Form for Minors
- Medical Release Form (Minor): Protected Health Information