4/1/25 changes Clone of GSCH New Patient Registration

Patient Registration

Insurance Coverage

Sliding-Fee Scale Discount Application

Informed Consent

Health History

Providers

Allergies

Medications

Hospitalizations

Surgical History

Birth History

Household Income Information

Release of Medical Information

Insurance Coverage
Do you have active insurance coverage?*

YesNo
I understand it is my responsibility to notify my insurance carrier of my choice of provider (please initial)*
Primary Insurance Carrier
Policy #
Group #
Subscriber's Name
Subscriber's Date of Birth
Relationship to Patient
Do you have secondary insurance or dental insurance?

YesNo
Secondary or Dental Insurance Carrier
Policy #
Group #
Subscriber's Name
Subscriber's Date of Birth
Relationship to Patient
Employer providing insurance coverage
If you have a scanned image of your insurance card, please upload it here:

Cancelof
How did you hear about us?
Are you transferring from another medical or dental office?*

YesNo
If yes, where?
Patient / Guardian Signature*

Clear
Date*

MonthDayYear
Date

Household Income Information
Because we receive government funding, we are required to report on the income levels of our patients as a group. This information is never shared in connection with your name. Thank you for providing this information.
Number of People in Household*
Annual Gross Household Income*
You may qualify for a discount based on your household income.*

I DO wish to apply for the discountI DO NOT wish to apply.I’d like an appointment to discuss insurance options.

Sliding-Fee Scale Discount Application
To apply, please provide the information below for everyone in your household.

PLEASE NOTE: You must submit proof of income within 30 days from the date of service or the date on this form. We will then determine your discount, which will be in effect for one year. Please provide proof of each type of income that any member of your family receives.

These are accepted proofs of income:
- 4 weeks of current, consecutive pay or unemployment stubs
- Retirement or pension documents
- Approval letters documenting Social Security, SSI, SSDI, TANF or other public assistance.
- Court documents for child support or alimony
- Current tax return

Household Income

If you have a scanned image of your proof of income, please upload it here:

Cancelof
If you have no income or do not have the types of proof listed above, please check this box. A staff member will contact you to discuss.
No Insurance? Want to learn about available options?

I'd like an appointment to discuss insurance options.
The above information supplied is current and accurate to the best of my knowledge. I understand that if information provided is found to be inaccurate, any discount given may be reversed.
Patient/Guardian Signature

Clear
Date

MonthDayYear
Date

Informed Consent
Greater Seacoast Community Health (GSCH, which includes Goodwin Community Health and Families First Health Center) asks patients to understand and agree to the information in this document. More information is available in separate documents, as noted below. If you have questions, please ask our office staff.

General Consent for Outpatient Diagnosis, Care and Treatment
- I have voluntarily come to Families First or Goodwin Community Health seeking medical, dental and/or behavioral health services.
- I give permission for providers at these practices to conduct examinations and tests, make referrals, and provide procedures and treatment needed for my diagnosis and care.
- These services may be provided in-office or by telehealth (phone or video), as agreed upon when my appointment is scheduled.
- I understand that any health treatment has potential risks and benefits and that I should discuss any concerns regarding the potential risks and benefits of any treatment with my, or my child’s, health care providers.
- I understand that GSCH provides a broad range of integrated services at multiple locations.
- I understand that the providers of all services at GSCH - including medical, dental, mental health, substance use disorder treatment, social work, family and other services - are part of the same care team and may share information as necessary to improve the quality and continuity of my care.
Confidentiality, Privacy and Disclosure of Health Information
- Federal and state laws ensure that communication between patients and their health care providers is confidential. In most cases we cannot and will not disclose health records to anyone outside your care team unless we have your written permission to do so. However, we are legally required to share information if: staff members suspect abuse, neglect or exploitation of a child or incapacitated adult; staff members suspect that patients might harm themselves or others; a patient makes a “serious threat of physical violence” to a person or property; a patient is impaired and unwilling to use alternatives to driving themselves; a medical emergency requires calling emergency services and/or transporting the patient to a hospital.
- GSCH is required by law to maintain the privacy of patients’ health information and to provide patients with the Notice of Privacy Practices. (Information on this notice is below.)
- GSCH may share information about patients, including Protected Health Information and information about alcohol and drug use, with a referring provider and/or integrated health partner with whom GSCH has a Business Associates Agreement for the continuity of patient care. (A Business Associates agreement is a signed agreement with another business or health care provider. It requires both parties to keep patients’ information confidential.)
Behavioral Health Services
- The Behavioral Health providers at Greater Seacoast Community Health are part of your care team. Any information a patient provides to the mental health providers, including information about mental health and/or alcohol and drug use, is recorded in the electronic health record. Providers and support staff who are involved in any aspect of patient care, or who are required to process health information for administrative purposes, are able to access this record without authorization.
- Under New Hampshire law, minors 12 years of age or older may voluntarily submit themselves to treatment for drug dependency or other drug-related problem without the consent of a parent or guardian. Any records related to such treatment are confidential unless the minor examined or treated consents in writing.
- If either you or your child are experiencing suicidal ideation or are at risk of self-harm you may be instructed to go to nearest ER for emergency assessment and/or hospitalization.
- Patients’ insurance may be billed for visits with behavioral health counselors that are longer than 15 minutes, even if they occur as part of a medical visit. Also, patients may be responsible for copays, depending on their insurance plan.
Achieving a Strong Patient-Provider Team Partnership

We value the relationships we build with our patients. Building this partnership between you and your care team begins with mutual trust and respect.

You can expect us to:
- treat you with courtesy and respect, in the office, on the phone and in the Patient Portal
- respect your personal, religious, and cultural beliefs
- protect your privacy and ensure your dignity
  respect your individual needs and wishes and meet them as much as we reasonably can
- work together as a team to create the best treatment plan for you
- make every effort to meet your needs in a timely way, while following our policies and procedures.
We expect you to:
- treat all staff and visitors with courtesy and respect, in the office, on the phone and in the Patient Portal
- keep your voice low enough that only the person you are speaking with can hear. This also keeps your protected health information private
- do your best to follow the treatment plan that you and your health care team have created
- let the team know if you have trouble following that plan.
Financial Responsibility Agreement and Assignment of Benefits
- I authorize Greater Seacoast Community Health to bill and receive payment from my insurance company for services rendered.
- I understand that I am financially responsible for all charges incurred that are not covered by my or my child's insurance company, including but not limited to deductibles and co-payments.
- I authorize the release of Personal Health Information necessary to file a claim and audit with my insurance company and assign benefits to the provider or group indicated on the claim.
Documents

Please read these three documents, which are available upon request from office staff and also on our website at tinyurl.com/GSCH-documents.
1. Patients Notice of Privacy and Use and Disclosure of Health Information
2. Patient Rights and Responsibilities in a Patient-Centered Medical Home
3. Financial Policy
Patient Acknowledgment

I understand the information contained in this Informed Consent document. I agree to the conditions set forth in the Informed Consent and in the other documents referenced above. Any questions I had about this consent have been answered. This consent will remain in effect unless I revoke it in writing, which I may do at any time.
Patient's Name*

First NameLast Name
Patient's Date of Brith*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date

Rows	Provider	Specialty
First Provider
Second Provider
Third Provider

Rows	Allergy	Reaction
Allergy 1
Allergy 2
Allergy 3

Rows	Current packs/day	# of years
Your cigarette usage

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 03801 (603) 422-8208 Fax (833) 448-2282Goodwin Community Health, 311 Route 108, Somersworth, NH 03878 (603) 749-2346 Fax (833) 448-2282
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 #*
Address*
Fax #
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
Other types of information that you authorize Greater Seacoast to obtain (specify):
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:

Rows	Medication	Dose (e.g. mg/pill)	How many times a day and when?
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8

Rows	Reason for Hospital Stay	Hospital Name	Dates of Stay (can be approximate)
Hospitalization 1
Hospitalization 2
Hospitalization 3
Hospitalization 4

Rows	Surgery/Operation Type	Where Surgery Was Done	Surgery Date (can be approximate)
Surgery 1
Surgery 2
Surgery 3
Surgery 4

Rows	Select if applicable	Relationship to patient
Alcoholism
Depression/suicide
High cholesterol
Bleeding/clotting problem
Cancer (specify type bleow)
Asthma/COPD
High blood pressure
Diabetes
Heart disease
Thyroid problem
Stroke
Other

Name (First, Middle Initial, Last)

Relationship to you

Income & Frequency

Income Type

Household Member 1

Household Member 2

Household Member 3

Household Member 4

Household Member 5