Use this form if you are employed by:
(PRH) Portsmouth Regional Hospital, (PRASC) Portsmouth Regional Ambulatory Surgery Center, (PMC) Parkland Medical Center, Holy Family Hospital - Methuen, MA, Andover Surgery Center, (DMC) Derry Medical Center, (LFP) Londonderry Family Practice, (SAL-RAD) Salem Radiology (PMC), Dartmouth-Hitchcock (Nashua)