OLD GSCH ROI New Patient

Release of Medical Information

for NEW Greater Seacoast Community Health patients
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Phone:*
Please enter a valid phone number.
I request that documents be released to Greater Seacoast Community Health at the following practice:*

Families First Health & Support Center, 8 Greenleaf Woods Dr., Portsmouth, NH 03801Goodwin Community Health, 311 Route 108, Somersworth, NHLilac City Pediatrics, 311 Route 108, Somersworth, NH 03878
I authorize Greater Seacoast Community Health to obtain the patient's personal health information from the facility or person named below.*

Obtain from
Name/Facility:*
Phone #*
Fax #
Address*
City, State, Zip*
Email
example@example.com
For dates of care from:

MonthDayYear
Date
To:

MonthDayYear
Date
Purpose of release:

New Patient
Please initial all types of information that you authorize us to obtain:
Medical diagnostic, testing, and treatment information
Dental diagnostic, testing and treatment information and /or x‐rays taken
Date of X-Rays taken:

MonthDayYear
Date
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:

MonthDayYear
Date
Information about sexually transmitted diseases and/or HIV/AIDS
Psychiatric/psychological evaluation(s), reports, assessments, summaries, psychotherapy notes or other documents with diagnosis, prognosis, recommendations, or testing records and behavioral observations
Drug and alcohol information including evaluation, diagnostic, treatment and progress notes.
Other types of information that you authorize Greater Seacoast to obtain (specify):
Initials authorizing release of information:
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:*

Clear
Date

MonthDayYear
Date
Name of Person Signing:

First NameLast Name
Relationship to Patient:
Please allow 30 days for the preparation of records.
Should be Empty:

Release of Medical Information