As an Mt. Ascutney Hospital and Health Center patient, you can review or request your medical records using the myDH patient portal website.
Note: If you don't have a myDH account, you can sign up on the myDH Sign Up web page.
Forms for medical record management
In some situations, you may need to complete and send a form to the Medical Records office to:
- Have your medical records sent to us.
- Authorize others to view and manage your medical records.
- Revoke permission for others to view or share your medical records.
- Request changes to your medical records.
- Request a copy of a decedent's medical record or autopsy report.
- Have copies of your medical record sent from us to someone else.
Please refer to the Dartmouth Health website for a list of medical records and release forms.
Read about medical records at MAHHC.
Please contact us if you have any questions.
Clinic registration forms
To register as a new patient at MAHHC, please download and complete these time-saving forms before your appointment. You may return the forms to MAHHC by mail, fax or in person. The proper fax number and mailing address are at the bottom of each form.
Forms related to medical services
Consent to treat a minor in the parent/guardian's absence
MAHHC can only provide non-emergency care to minors with the consent of their parents or guardians. Complete and return this form to provide consent for a minor's appointment. Please include current contact information.
When completed, please fax the form to 802-674-7314 or mail it to Mt. Ascutney Physicians Practice. Please visit our Locations & Directions page for our mailing address.
Request for ethics consultation
If you have an ethical question or concern about medical care, the MAHHC Ethics Committee welcomes the opportunity to assist you. Complete this referral form to request a consultation. Mail the completed form to Jill Lord, Ethics Chair, in MAHHC Administration. Please visit our Locations & Directions page for our mailing address.
We will contact you to schedule a meeting with the appropriate people involved. Please call Jill Lord, Ethics Chair, at 802-674-7224 if you have any questions.