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Call: 603-536-4000 Text: 802-424-8597
Call: 603-536-4000 Text: 802-424-8597
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Commonly Requested Forms
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5
Commonly Requested Forms
Medical Patient Forms
New Patient Package
Release of Information
Dental Patient Forms:
New Patient Package
Physical Therapy:
New Patient Package
Physical and Occupational Therapy Consent Form
Behavioral Health:
New Patient Package
BH Informed Consent
RISE Recovery Patient Forms:
New Patient Package
Part 2 Authorization to Release PHI (Substance Use Related Services)
Intensive Outpatient Program (IOP) Treatment Agreement
Other Forms:
Sliding Fee Discount Program Application
Telehealth Consent to Treat
Personal Representative Designation Form
Revocation of Personal Representative Form
Consent to Treat – Minor
NHIIS Opt Out Form
Patient Consent to Permit Health Information Sharing between Mid-State and:
Speare Memorial Hospital
Dartmouth-Hitchcock Medical Center