Commonly Requested Forms

Commonly Requested Patient Forms

New Patient Packet

Dental History Form

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

Mid-State Health Center’s Patient Bill of Rights

Patient Consent Form

Summary of Billing and Payment Policies

Record Release to Mid-State

Record Release from Mid-State

Pre-Op Request Form

Treatment Agreement

Developmental History

Medicare Secondary Payer


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

Speare Memorial Hospital

Dartmouth-Hitchcock Medical Center


New Hampshire Accountable Care Partners ACO:

New Hampshire Accountable Care Partners Notice & Information for Patients