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Application and Consent Forms

If you are interested in setting up CIS Affiliate Access for your practice:
Please contact DHMC Regional Information Systems (603-653-3272) for information on setting up a practice agreement.

The following forms can still be used for the individual CIS Affiliate (Affiliate Information System) accounts:

• Affiliate Account Request Form (pdf format)
  This form needs to be completed by the provider before activation of the Affiliate system can occur. Please mail or fax the form back to Dave Hale at the address/number at the top of the form.
  
  
• AIS Patient Notice (pdf format)
  This is the form that that patients will sign to release their DHMC electronic medical record to providers. Note that more than one provider can be listed on this form. (Use the Southern Region version of this form if you have a Southern Region AIS account)
  
  
• DHPG Policy Statement (pdf format)
  This is the confidentiality policy that all Affiliates agree to when signing up for a CIS Affiliate account.

• Affiliate Consent Revocation Form (pdf format)
  This form can be used by a patient to revoke any previously established authorization to share electronic medical records through any of the CIS Affiliate models.

Attachments:
AIS Account Request Form (PDF)
AIS Patient Consent Form (PDF)
AIS Patient Consent (Southern Region) (PDF)
Dartmouth-Hitchcock Privacy and Confidentialty Policy (PDF)
Affiliate Consent Revocation Form (PDF)