Additional Forms

Record Release To/From Mid-State

Pre-Op Request Form 

Developmental History 

Medicare Secondary Payer

Designation of a Personal Representative

Revocation of a Personal Representative

Patient Consent Form

Minor Consent Form

Telemedicine Consent Form

NHIIS Opt-Out Form

Other Important Information

Mid-State Health Center’s Notice of Privacy Practices (HIPAA Notice) 

Mid-State Health Center’s Patient Bill of Rights 

Summary of Billing and Payment Policies 

Patient Consent to Permit Health Information Sharing between Mid-State and:

Speare Memorial Hospital

Dartmouth-Hitchcock Medical Center