1 GSCH Patient Registration

Patient's Legal Name:*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Which practice/location of care would you like to go to?*

Families First Health & Support Center, 8 Greenleaf Woods Drive, Portsmouth, NHGoodwin Community Health, 311 Route 108, Somersworth, NHLilac City Pediatrics, 311 Route 108, Somersworth, NH (pediatric ONLY)

I authorize Greater Seacoast Community Health to receive health documents from the facility or provider named below:

Name of facility or provider where you have received care in the past:*

Phone #*

Fax #*

Address

City, State, Zip

Email

example@example.com

For dates of care from:

Date

To:

Date

Purpose of release*

Important: In order to process your aplication, please put your INITIALS (or NA if it does not apply) next to the information you want shared with your medical team/s.

Medical diagnostic, testing, and treatment information*

Dental diagnostic, testing and treatment information and /or x‐rays taken*

Records of immunizations and physicals*

Current prenatal records, copies of all lab tests (including HIV results) and/or scans*

Summary of labor and delivery notes for the following date of delivery

Date of delivery

Date

Information about sexually transmitted diseases and/or HIV/AIDS*

Psychiatric/psychological evaluation(s), reports, assessments, summaries, psychotherapy notes or other documents with diagnosis, prognoses, recommendations, or testing records and behavioral observations*

Drug and alcohol information including evaluation, diagnostic, treatment and progress notes.*

Other:

Type what information that you authorize us to release or obtain:

Methods of Disclosure Authorized: Faxed, written, phone conversation, in-person and/or secure e-mail.

I understand that I may revoke (withdraw) this authorization at any time by notifying the practice in writing. Revocation will be effective as of date received.
I understand that a revocation will not apply to: 1)any actions that this practice has already taken while relying on this authorization before I revoke it; or 2) if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right
I understand that I might be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes.
I understand that the recipient of some information disclosed under this authorization may re-disclose this information and that the information will no longer be protected by federal privacy regulations.
I understand that I have the right to: 1) Inspect or copy the protected heath information to be used or disclosed as permitted under Federal law; 2) Refuse to sign this authorization.
This authorization will remain in effect for one year and may be revoked at any time by notifying this practice in writing.
Unless otherwise noted, only the past two years of electronic records as stipulated above will be sent.

Signature of Patient and/or Legal Representative Signature of Patient and/or Legal Representative. NOTE: INITIAL OR NON LEGAL SIGNATURE WILL BE DENIED

Clear

Date

Release of Medical Information