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

Summary of Billing and Payment Policies

Record Release (To or From)

Pre-Op Request Form

Treatment Agreement

Developmental History

Medicare Secondary Payer

Designation of Personal Representative

Revocation of Personal Representative



Patient Consent Form

Minor Consent Form

Telemedicine Consent

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

Dental Informed Consent

Behavioral Health Informed Consent


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