Families First Health Center, 8 Greenleaf Woods Drive, Portsmouth, NH 03801
Ph: 603‐422-8208 Fax: 603‐422‐8218
Please INITIAL all types of information that you authorize us to release or obtain:
Methods of Disclosure Authorized: Faxed, written, phone conversation, in‐person and/or secure e‐mail
To receiving provider: This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2) The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise per- mitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
For office use only: Witness:
I. TRANSFER OF CARE QUESTIONNAIRE
We care what you think! We would like your feedback on the care you received while a patient at Families First Health Center the reason for transferring your care. Please take a few minutes to complete the following questionnaire. Any suggestions and comments are appreciated. Thank you for your time.
2)Please answer these questions regarding office operations:
Thank you for taking the time to complete the questionnaire. Your thoughts are valuable to us. If we can be of further assistance, please do not hesitate to call us.
II.IMPORTANT INFORMATION FOR PATIENTS WHO ARE LEAVING GCH:
1. We will be closing your case with our health center. If at any time you desire to return to the health center, we would be happy to welcome you back. Please call the office to re-establish care.
2. If you have family members who come to the health center and are also transferring their care, please tell us as soon as possible so we can cancel their future appointments as well.
3. If you need additional information, please call Medical Records at 603-994-6343.