1 GSCH Patient Registration

Release of Medical Information
Release of Medical Information
Patient's Legal Name: *

First Name Last Name
Date of Birth *

Month Day Year
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, NH Goodwin Community Health, 311 Route 108, Somersworth, NH Lilac City Pediatrics, 180 Farmington Rd., Rochester, 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:

Month Day Year
Date
To:

Month Day Year
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

Month Day Year
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 (please make it as big as box size) NOTE: INITIAL OR NON LEGAL SIGNATURE WILL BE DENIED

Clear
Date

Month Day Year
Date
Should be Empty:

Release of Medical Information

Release of Medical Information