Counseling & Human Development
Dick's House, 2nd Floor
7 Rope Ferry Road
Hanover, NH 03755
Phone: (603) 646-9442
Fax: (603) 646-9410
The Counseling & Human Development (CHD) staff cannot disclose/share your Protected Health Information (PHI) without your prior consent. If you would like copies of your CHD records or you would like information shared with someone else you must first submit a completed ROI (below):
The completed ROI can be faxed to (603) 646-9410 (ATTN: CHD) or emailed to CHD@Dartmouth.edu.
NOTE: We do require the originally signed document. Please mail the original ROI to: CHD, 7 Rope Ferry Road, Hanover, NH 03755.
Section #1 of the ROI: Check off the information you would you like released.
Section #2 of the ROI: Check off who you are releasing your PHI (Protected Health Information) to as well as how (mail, phone or fax). Due to confidentiality and security reasons we elect not to email PHI.
Section #3 of the ROI: Check off the purpose of the disclosure.
Authorization Expiration Date: If an expiration date is not indicated the ROI will expire one year from the 'date signed'.
Section #4 of the ROI: If applicable, INITIAL in the appropriate blank authorizing disclosure of Alcohol or Drug Treatment Records and HIV Status.
Signature and Date Signed: Please be sure to sign and date the ROI. Please also fill in your contact phone number, date of birth and graduation year.
Please allow up to 2 weeks for processing.
Contact the CHD office with any questions, (603) 646-9442.
Last Updated: 3/6/17