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Commonly Requested Forms

Patient Forms and Consents

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

Summary of Billing and Payment Policies

Record Release To/From Mid-State

Pre-Op Request Form

Treatment Agreement

Developmental History

Medicare Secon dary Payer

Designation of a Personal Representative

Revocation of a Personal Representative

Patient Consent Form

Minor Consent Form

Telemedicine Consent Form

Part 2 Authorization to Release PHI (Substance Use Related Services)

Dental Informed Consent

Intensive Outpatient Program (IOP) Treatment Agreement

NHIIS Opt-Out Form

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

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