newport health center 11 john stark highway newport, nh ... · timothy lin, md* sarah seo, md*...
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Newport Health Center
11 John Stark Highway
Newport, NH 03773
(603) 863-4100
Dear Patient,
Thank you for choosing the Newport Health Center for your medical needs. Our goal is
to provide you with quality care every time.
To ensure that your Newport Health Center team has all of your medical information, we
ask that you complete the highlighted areas and sign the attached Authorization for
Release of Medical Records so we may request your records from your previous medical
provider. Please note that if you do not fill in the entire Medical Record release form it
will hold up the request of your records and delay your first appointment. Your records
may take up to 30 days to receive; you will be contacted once your records have been
processed.
Also, please complete the Patient Information and Patient History Forms. You may
return all forms by mail or drop them off at the Newport Health Center Medical Records
Department.
The following providers are available to see new patients in the areas of infancy to
elderly care. Please select a provider preference:
____ Nicole Poudrette, APRN
____ Benjamin Holobowicz Jr MPAS, PA-C
____ Melissa Nelson APRN
____ Shannon Schachtner APRN
____ Oliver Herfort MD (Adult only)
____ Rebeccca Lozman-Oxman DNP, CPNP, MPH (Pediatric only)
If you do not have a provider preference please select: Male / Female
Your provider preference will be taken into consideration by the Medical Director
who reviews all new patient requests.
Upon completion of your acceptance as a new patient at Newport Health Center,
you will receive a call to set up your “establish care visit” this is typically a well visit
or yearly exam.
If you have any questions, please contact us at 603-863-4100.
The Newport Health Center team looks forward to taking care of your healthcare needs.
PLEASE RETURN THIS FORM WITH YOUR PACKET
Patient Information Sheet Rev Date: 05/18/17 NHC
PATIENT INFORMATION
Name: _____________________ _____________________ _____ Last First MI
Phone: _____________________ _____________________ __________________ Home Work Cell
Mailing address: __________________________ Street Address ________________________
__________________________ ________________________
Sex: M F DOB: ____/____/____ SSN: ______-______-________
Marital Status: M S D W Sep
Employed: FT PT Self Ret Military Not employed
Spouse’s Name: _____________________ Spouse’s Phone: ___________________
Emergency Contact (other than spouse): _________________________
Phone: ___________________ Relationship: ___________________
Employer: ______________________________________ Student: FT PT
GUARANTOR INFORMATION
Same as above: if patient is over 18 years of age
Name: _____________________ _____________________ _____ Last First MI
Phone: _____________________ _____________________ __________________ Home Work Cell
Mailing address: __________________________ Street Address ________________________
__________________________ ________________________
Sex: M F DOB: ____/____/____ SSN: ______-______-________
Employer: ______________________________________
INSURANCE INFORMATION
Insurance Company: _____________________________________________________________
Subscriber Name: _______________________________________
Certificate #: _____________________ Group Name / Number: _____________________
Please present insurance card(s) to the front desk. Any co-payment is due at time of service.
HEALTH HISTORY
Form #:NHC1068 *NHC1068* Rev Date: 8/28/2018 Page 1 of 2
Name:__________________________________________________________________ Date:__________________________ Age:__________________ Birthdate:________________ Date of Last Physical Exam:________________________ What is the Reason for Today’s Visit?____________________________________________________________________________
SYMPTOMS: CHECK (X) BOX FOR SYMPTOMS YOU CURRENTLY HAVE, OR HAVE HAD IN THE PAST YEAR
GENERAL GENITAL/URINARY WOMEN ONLY
Chills Blood in Urine Abnormal Pap Smear
Depression Frequent Urination Bleeding Between Periods
Dizziness Lack of Bladder Control Breast Lump
Fainting Painful Urination Extreme Menstrual Pain
Fever EYE, EAR, NOSE & THROAT Hot Flashes
Forgetfulness Bleeding Gums Nipple Discharge
Headache Blurred Vision Painful Intercourse
Loss of Sleep Crossed Eyes Vaginal Discharge
Loss of Weight Difficulty Swallowing Date of Last Period:
Weight Gain Double Vision Date of Last Pap Smear:
Nervousness Earache Date of Last Mammogram:
Numbness Ear Discharge Number of Children:
Sweats Hay Fever Are You Pregnant?
GASTROINTESTINAL Hoarseness MEN ONLY
Poor Appetite Loss of Hearing Breast Lump
Bloating Nosebleeds Erection Difficulties
Bowel Changes Persistent Cough Lump in Testicles
Constipation Ringing in Ears Penis Discharge
Diarrhea Sinus Problems Sore on Penis
Excessive Hunger Vision - Flashes Other
Excessive Thirst Vision - Halos CARDIOVASCULAR
Gas SKIN Chest Pain
Hemorrhoids Bruise Easily High Blood Pressure
Indigestion Hives Irregular Heartbeat
Nausea Itching Low Pressure
Rectal Bleeding Change in Moles Poor Circulation
Stomach Pain Rash Rapid Heart beat
Vomiting Scars Swelling of Ankles
Vomiting Blood Sores that Won’t Heal Varicose Veins
MUSCLE/JOINT/BONE ALLERGIES: Medications/Substances MEDICATIONS YOU CURRENTLY TAKE
Pain, Weakness, Numbness in:
Arms Hips
Back Legs
Feet Neck
Hands Shoulders
Pharmacy Name
Pharmacy Name #
HEALTH HABITS OCCUPATIONAL CONCERNS SERIOUS ILLNESS/INJURY How often do you use these Substances: Check if your work exposes you to: DATE OUTCOME
Alcohol: Stress: Yes No
Tobacco: Hazardous Substances: Yes No
Caffeine: Heavy Lifting: Yes No
Drugs: Other: Yes No
Other: Your Occupation:
HEALTH HISTORY (cont’d)
Form #: NHC1068 *NHC1068* Rev Date: 8/28/2018 Page 2 of 2
Name: DOB:
CONDITOINS: CHECK (X) BOX FOR CONDITIONS YOU CURRENTLY HAVE, OR HAVE HAD IN THE PAST YEAR
AIDS Glaucoma Pacemaker
Alcoholism Goiter Pneumonia
Anemia Gonorrhea Polio
Anorexia Gout Prostate Problems
Appendicitis Heart Disease Psychiatric Care
Arthritis Hepatitis Rheumatic Fever
Asthma Hernia Scarlet Fever
Bleeding Disorders Herpes Stroke
Breast Lump High Cholesterol Suicide Attempt
Bronchitis HIV Positive Thyroid Problems
Bulimia Kidney Disease Tonsillitis
Cancer Liver Disease Tuberculosis
Cataracts Measles Typhoid Fever
Chemical Dependency Migraine Headaches Ulcers
Chicken Pox Miscarriage Vaginal Infections
Diabetes Mononucleosis Vaginal Disease
Emphysema Multiple Sclerosis
Epilepsy Mumps
Check (X) If your blood relatives had any of
FAMILY HISTORY the following:
Relation Age State of Health
Age at Death
Cause of Death
Disease Relationship to You
Father Arthritis, Gout
Mother Asthma, Hay Fever
Brothers: Cancer
Chemical Dependency
Diabetes
Heart Disease, Strokes
Sisters: High Blood Pressure
Kidney Disease
Tuberculosis
Other
HOSPITALIZATIONS PREGNANCY HISTORY
Year Name of Hospital Reason & Outcome Year of Birth
Gender
Complications
M/F
M/F
M/F
M/F
M/F
M/F
M/F
Have you ever had a Blood Transfusion? Yes No If Yes, Approximate Date(s) ?
Form# NLH1070
*NLH1070* Revision Date: 3/14/2019
Originating Department: Medical Records Page 1 of 3
New London Medical Group/NHC Patient Authorization
Patient Name: __________________________________ Date of Birth: __________________________
I give the following person (s) permission to have access to:
Please check all that applies:
Discuss only Medical Information (No release of medical records)
Access to my Portal both Hospital and Medical Group
Pick up Prescriptions
_______________________________________ _______________________________________
Name Relationship to Patient
_______________________________________ _______________________________________
Name Relationship to Patient
_______________________________________ _______________________________________
Name Relationship to Patient
I have read the above and authorize the disclosure of the protected health information as stated.
_______________________________________ _______________________________________
Signature of Patient/Guardian/Representative Date
_______________________________________
Relationship to Patient
**** Expires 1 year from date signed
Name: DOB:
Date Script Name Printed Name Signature
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI)
Revised 03/01/19
Section A: This section must be completed for all Authorizations
Patient Name (please include Maiden Name and/or Aliases):
Birth Date:
Obtain information from: OR Release information to:
Provider’s Name: Recipient’s Name:
Newport Health Center Address 1: Address 1:
11 John Stark Highway
Address 2: Address 2:
City:
State:
Zip:
City:
Newport State:
NH Zip:
03773 Phone: Fax: Phone:
603-865-2855 Fax:
This authorization will expire on the following: (Fill in the Date or the Event but not both.)
Date: Event:
Purpose of disclosure:
Format of Record: Paper CD
Preferred Provider: Description of information to be used or disclosed
Is this request for psychotherapy notes?
Yes, then this is the only item you may request on this authorization. You must submit another authorization for other items below.
No, then you may check as many items below as you need.
Description: Date(s): Description: Date(s): Description: Date(s):
Complete Medical Record
Admission forms
H&P/Discharge Summary
Physician orders
Physician Progress Notes
Medication Records
Laboratory Reports
Radiology Reports
Radiology Images (on CD)
Special tests
Rehab Notes
Nursing Notes
Transfer forms
Emergency Room Records
Immunizations
Itemized bill:
Other:
Other:
I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV
results, AIDS, or genetic testing information. _______________ (Initial) If not applicable, check here.
I understand that:
1. I may refuse to sign this authorization and that it is strictly voluntary.
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the
revocation. Further details may be found in the Notice of Privacy Practices.
4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal
privacy regulations and may be redisclosed.
5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it.
6. I get a copy of this form after I sign it.
Section B: Is the request of PHI for the purpose of marketing?
If yes, the health care provider must complete Section B, otherwise skip to Section C.
Will the recipient receive financial or in-kind compensation in exchange for using or disclosing this information?
If yes, describe:
Yes No
Section C: Signatures
I have read the above and authorize the disclosure of the protected health information as stated.
Signature of Patient/Guardian/Patient Representative:
Date:
Print Name of Patient/Patient Representative:
Relationship to Patient:
Andrew Torkelson, MDTeresa M. Godsell, AuD*
AUDIOLOGY (Hearing Testing)603-526-5172
Benita Walton, MD
BEHAVIORAL HEALTH603-526-5172
Vicki Anderson, PSY
CARDIOLOGY603-526-5162
Siddhartha Parker, MD, MA*
Sean D. Bears, MD*
GASTROENTEROLOGY603-526-5172
Michael Paul, MD* Catherine Schneider, MD Lauren Wilson, MD*
GENERAL SURGERY603-526-5172
GYNECOLOGY603-526-5450
Eileen Kirk, MD Kris Strohbehn, MD*
Lawrence R. Jenkyn, MD
Emily E. Shaughnessy, MD*
NEUROLOGY603-526-5172
DERMATOLOGY603-650-3100
Joseph M. Phillips, MD Alyssa M. Pearl, PA
SPINE/NEUROSURGERY603-526-5408
Harold J Pikus, MD Rebecca Zebo, PA
Rodwell Mabaera, MD*
ONCOLOGY603-526-5162
Kevin Dwyer, MD* Jan Idzikowski, PA-C Stephen R. Kantor, MD
ORTHOPAEDICS603-526-5314 (Lin) 603-526-5172 (Idzikowski, Kantor & Murphy)
Timothy Lin, MD* Sarah Seo, MD*
OTOLARYNGOLOGY (ENT) 603-526-5172
New London Hospital • 273 County Road, New London, NH 03257 • 603-526-2911 • NewLondonHospital.org
PAIN MANAGEMENT603-526-5162
Aram Kalpakgian, PA-C Sarah Stuart Lester, MD Miriam N. Cordell, CNM, MS*
Brian J. Frenkiewich, DO
PEDIATRICS603-526-5363
PRE/POST NATAL CARE603-526-5450
OSTEOPATHIC MANIPULATIVE MEDICINE603-526-5544
Janice E. Gellis, MD*
PRIMARY CARE: INTERNAL MEDICINE603-526-5544
Elaine M. Silverman, MD Denise Weber, MD
RHEUMATOLOGY603-526-5172
Lin Brown, MD*
*Dartmouth-Hitchcock Provider
Timothy C. Ryken, MD*
Lawrence M. Dagrosa, MD*
UROLOGY603-526-5162
APRIL 2019
James M. Murphy, MD
Rebecca Wood, MD
Hulda Magnadottir, MD
603-526-5172
Michael Grant, MD*
Brian J. Frenkiewich, DOChristine Dube, MS, APRN
Erin Knuuti, FNP, MSN Griffin Manning, APRN Amy Schneider, MD
PRIMARY CARE: FAMILY MEDICINE603-526-5544
Oliver Herfort, MD Benjamin Holobowicz, JR, MPAS, PA-C
FAMILY MEDICINEINTERNAL MEDICINE
Melissa M. Nelson, MSN, APRN
Shannon Schachtner, APRN
Lawrence Schissel, MD
Eileen Kirk, MD
GYNECOLOGY
Rebecca L. Lozman-Oxman, DNP, CPNP, MPH
Richard “Pete” Peterson, PA-C, ATC
PEDIATRICS
NEWPORT HEALTH CENTER603-863-4100
ORTHOPAEDICS
New London Hospital • 273 County Road, New London, NH 03257 • 603-526-2911 • NewLondonHospital.org
Benita Walton, MDChris Lopez, PharmD, BCACP, CDE
BEHAVIORAL HEALTHCLINICAL AMBULATORY PHARMACY/DIABETES EDUCATION & MANAGEMENT
ADDITIONAL SERVICES• Diagnostic Imaging and Radiology services
including 3D Mammography, Magnetic Resonance Imaging (MRI), Computed Tomography (C.T. Scan), Ultrasound, and Bone Mineral Density Testing
• Sports Medicine and Therapy Services including both Physical Therapy and Occupational Therapy
• Cancer Treatment (Dartmouth-Hitchcock specialists)
• Cardiac Stress Testing• Emergency Medical Services (EMS) providing
round the clock paramedic level 911 service for seven surrounding towns
• Nutrition Counseling• Regional Wellness Education• Advance Care Planning
Chris Lopez, PharmD, BCACP, CDE
CLINICAL AMBULATORY PHARMACY / DIABETES EDUCATION & MANAGEMENT603-526-5544
*Dartmouth-Hitchcock Provider
John Malcolm, MD
Nicole Poudrette, APRN