11 John Stark Highway Newport, NH 03773 (603) 863-4100
Newport Health Center11 John Stark HighwayNewport, NH 03773(603) 863-4100Dear Patient,Thank you for choosing the Newport Health Center for your medical needs. Our goal isto provide you with quality care every time.To ensure that your Newport Health Center team has all of your medical information, weask that you complete the highlighted areas and sign the attached Authorization forRelease of Medical Records so we may request your records from your previous medicalprovider. Please note that if you do not fill in the entire Medical Record release form itwill hold up the request of your records and delay your first appointment. Your recordsmay take up to 30 days to receive; you will be contacted once your records have beenprocessed.Also, please complete the Patient Information and Patient History Forms. You mayreturn all forms by mail or drop them off at the Newport Health Center Medical RecordsDepartment.The following providers are available to see new patients in the areas of infancy toelderly care. Please select a provider preference:Benjamin Holobowicz Jr MPAS, PA-CMelissa Nelson APRNShannon Schachtner APRNOliver Herfort MD (Adult only)Rebeccca Lozman-Oxman DNP, CPNP, MPH (Pediatric only)Amanda Dostaler DOIf you do not have a provider preference please select: Male / FemaleYour provider preference will be taken into consideration by the Medical Directorwho 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 wellvisit 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 ng address:Street AddressSex:MFDOB: / /SSN: - -Marital �s Name:Not employedSpouse’s Phone:Emergency Contact (other than spouse):Phone:Relationship:Employer: Student:FTPTGUARANTOR INFORMATIONSame as above: if patient is over 18 years of ageName:LastPhone:HomeFirstMIWorkCellMailing address:Street AddressSex:MFDOB: / /SSN: - -Employer:INSURANCE INFORMATIONInsurance 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.Patient Information SheetRev Date: 05/18/17NHC
Pediatric DemographicsPatient’s Name:MPhysical Address:Date of Birth:Mailing Address:SS # (optional):Home Phone #:Cell Phone #:1st Legal Parent/Guardian:Relationship:Physical Address:Date of Birth:Mailing Address:SS # (optional):FHome Phone #:Cell Phone#Work Phone #:Place of employment:2nd Legal Parent/Guardian:Relationship:Physical Address:Date of Birth:Mailing Address:SS # (optional):Home Phone #:Cell Phone #:Work Phone #:Place of employment:Insurance Company:Certificate/ID #:Subscriber/Guarantor Name:Group #:Patient Sibling’s NamesDate of BirthPatient Sibling’s NamesDate of BirthAre there any other person’s living in the household? (step‐parents/siblings, significant other, foster children, etc.):NOTES: (custody arrangements, adoption, language or communication barriers, etc.)Form# PP12Revision Date: 06/27/17Originating Department: PEDsPage 1 of 2*PP12*
HEALTH HISTORYName:Age:Birthdate:Date: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 orgetfulnessHeadacheLoss of SleepLoss of WeightWeight GainNervousnessNumbnessSweatsGASTROINTESTINALPoor AppetiteBloatingBowel ChangesConstipationDiarrheaExcessive HungerExcessive ThirstGasHemorrhoidsIndigestionNauseaRectal BleedingStomach PainVomitingVomiting BloodMUSCLE/JOINT/BONEPain, Weakness, Numbness RINARYBlood in UrineFrequent UrinationLack of Bladder ControlPainful UrinationEYE, EAR, NOSE & THROATBleeding GumsBlurred VisionCrossed EyesDifficulty SwallowingDouble VisionEaracheEar DischargeHay FeverHoarsenessLoss of HearingNosebleedsPersistent CoughRinging in EarsSinus ProblemsVision - FlashesVision - HalosSKINBruise EasilyHivesItchingChange in MolesRashScarsSores that Won’t HealALLERGIES: Medications/SubstancesWOMEN ONLYAbnormal Pap SmearBleeding Between PeriodsBreast LumpExtreme Menstrual PainHot FlashesNipple DischargePainful IntercourseVaginal DischargeDate of Last Period:Date of Last Pap Smear:Date of Last Mammogram:Number of Children:Are You Pregnant?MEN ONLYBreast LumpErection DifficultiesLump in TesticlesPenis DischargeSore on PenisOtherCARDIOVASCULARChest PainHigh Blood PressureIrregular HeartbeatLow PressurePoor CirculationRapid Heart beatSwelling of AnklesVaricose VeinsMEDICATIONS YOU CURRENTLY TAKEPharmacy NamePharmacy Name #HEALTH HABITSOCCUPATIONAL CONCERNSHow often do you use these Substances:Check if your work exposes you ardous Substances:Heavy Lifting:Other:Your Occupation:Form #:NHC1068Rev Date: 8/28/2018Page 1 of 2YesYesYesYesSERIOUS ILLNESS/INJURYDATEOUTCOMENoNoNoNo*NHC1068*
HEALTH HISTORYName:(cont’d)DOB:CONDITOINS: CHECK (X) BOX FOR CONDITIONS YOU CURRENTLY HAVE, OR HAVE HAD IN THE PAST AnemiaGonorrheaPolioAnorexiaGoutProstate ProblemsAppendicitisHeart DiseasePsychiatric CareArthritisHepatitisRheumatic FeverAsthmaHerniaScarlet FeverBleeding DisordersHerpesStrokeBreast LumpHigh CholesterolSuicide AttemptBronchitisHIV PositiveThyroid ProblemsBulimiaKidney DiseaseTonsillitisCancerLiver DiseaseTuberculosisCataractsMeaslesTyphoid FeverChemical DependencyMigraine HeadachesUlcersChicken PoxMiscarriageVaginal InfectionsDiabetesMononucleosisVaginal DiseaseEmphysemaMultiple SclerosisEpilepsyMumpsCheck (X) If your blood relatives had anyofFAMILY HISTORYthe following:RelationAgeState ofAge atCause ofDiseaseRelationship toHealthDeathDeathYouFatherArthritis, GoutMotherAsthma, Hay t Disease,StrokesHigh Blood PressureSisters:Kidney DiseaseTuberculosisOtherYearHOSPITALIZATIONSName of HospitalReason & OutcomeHave you ever had a Blood Transfusion?Form #: NHC1068Rev Date: 8/28/2018Page 2 of 2YesPREGNANCY HISTORYGendeComplicationsrM/FM/FM/FM/FM/FM/FM/FNo If Yes, Approximate Date(s) ?Year ofBirth*NHC1068*
Use this form when you want a health careprovider to send your medical records to D-HH.PERMISSION TO SEND HEALTH INFORMATION TO ADARTMOUTH-HITCHCOCK AFFILIATED COVERED ENTITYPATIENT INFORMATIONPatient Name:Date of Birth:Address:City:Phone Number:(State:Zip:)SENDERI authorize:Name of Provider:Street Address:Fax Number:City:()State:Zip:RECIPIENTto share (disclose) my health information with Dartmouth-Hitchcock Health at the following location(s):q Newport Healthq Alice Peck Day q Cheshireq Concord DHq DHMCq Manchester DH q Nashua DHHealth InformationServicesPh: (603) 448-7433Fax: (603) 640-1984Medical CenterHIM Dept.Ph: (603) 354-5477Fax: (603) 354-6530Medical Release Dept.Ph: (603) 229-5145Release of InformationPh: (603) 650-7110Fax: (603) 229-5146Fax: (603) 727-7869Health InformationServicesPh: (603) 695-2820Fax: (603) 676-4290Health InformationServicesPh: (603) 577-4037Fax: (603) 577-4039CenterRelease of InformationPh: (603) 863-2855Fax: (603) 863-3585If mailing my information, please return requested records to the following department/section or provider:HEALTH INFORMATION TO BE SHAREDCopies of my health information within the following dates: toDischarge SummaryEmergency Department ReportsImmunizationsInpatient Progress NotesLaboratory/Pathology reportsOperative ReportsOutpatient Visit (Office) NotesSchool Physical FormsX-Ray ReportsX-Ray FilmsOtherRecords from a Specific Provider:For the following purpose:SENSITIVE HEALTH INFORMATIONIf the information to be disclosed contains any of the following types of information listed below, additional laws and/or signaturerequirements may apply. I understand and agree that this information will be sent to Dartmouth-Hitchcock Health toinclude the location noted above UNLESS I place my initials in the applicable space below, next to the type of records:Mental health treatment recordsSexually Transmitted Disease (STD) treatment recordsGenetic testingAlcohol/drug abuse treatment recordsHIV/AIDS test resultsDURATION & REVOCATIONThis authorization will remain in effect for one year from the date of the signature below, unless I specify a different date here:(date). I or my Personal Representative may revoke this authorization at any time by providing notice as specified in thesending provider’s Notice of Privacy Practices; however, my revocation will not apply to any previously released information.ADDITIONAL INFORMATIONI understand that: Dartmouth-Hitchcock Health and [SENDER NAME] will not condition my ability to receivehealthcare services on providing or refusing to provide this authorization. Once this information is shared with the recipient I havespecified above, how that recipient further discloses it may no longer be protected under federal and state privacy regulations. Mysending healthcare provider may require fees to process my request.SIGNATURESignature of Patient or Personal RepresentativeDatePrinted Name of Patient or Personal RepresentativeDescription of Personal Representative’s AuthorityHealth Information Services: 10/10/2019EFMC: 10/10/2019Do Not Scan to eD-H Medical Record
INSTRUCTIONS:How to use “Permission to Send Health Information to Dartmouth-Hitchcock” formThis form should be used when you want your health care provider to send your medical records to Dartmouth-Hitchcock.If you want D-H to send to your medical records to another health care provider or other third party, please use the“Permission to Share Patient Health Information” authorization form. You can find the form at: ion/medical records release forms.htmlPlease note that the sending health care provider’s office may have additional requirements forauthorizing records to be released to Dartmouth-Hitchcock.PATIENT INFORMATIONComplete each box as indicated with the following information: Patient’s name (please print clearly) Patient’s date of birth Patient/Personal Representative’s phone number Patient’s mailing address, including City, State, and Zip CodeSENDERPlease fill in which health care provider you are authorizing to send your medical records to Dartmouth-Hitchcock: Provider’s name or Provider’s office/practice name Mailing address of the health care provider, including Street, City, State, and Zip Code Fax number of the health care provider’s officeRECIPIENTCheck the Dartmouth-Hitchcock Health location where you would like your information sent. You may check multiplelocations. If you would like your records to be sent to a specific health care provider at Dartmouth-Hitchcock Health, pleasefill in the appropriate provider’s name or department/section (e.g., Pediatrics, Orthopedics, etc.).HEALTH INFORMATION TO BE SHAREDFill in the date range that applies to the health information you are requesting to be sent to Dartmouth-Hitchcock.Check the box(es) that describe the information you are requesting to be sent to Dartmouth-Hitchcock. For multi-provider group practices, you can indicate you want to have records sent from only a specific provider bychecking the “Records from a specific provider” box and filling in the relevant provider’s name.Fill in a description of the purpose of the requested records. Examples: Transfer to new provider, facilitate treatment,summarize treatment, etc. This section must be completed in order for the form to be valid.SENSITIVE HEALTH INFORMATIONDepending on the state where your health care provider practices, additional laws and/or signature requirements may applyto releases of “sensitive” categories of health information. If you do not place your initials in the spaces provided, the healthcare provider may release such sensitive information as necessary to fulfill your request.DURATION & REVOCATIONYour authorization will remain valid for one year from the date of your signature, unless you specify a different date in thespace provided. You have the right to revoke your permission at any time. Note that your revocation will not apply to anypreviously released information. Please revoke by following the directions in the health care provider’s Notice of PrivacyPractices, or call the provider’s office where your records are located.ADDITIONAL INFORMATIONPlease read this section on the form. Please fill in the blank space with the sending health care provider’s name.SIGNATURESign and date the authorization. Patients between the ages of 12 and 17 may be required to sign the form in addition totheir parent/legal guardian, depending on the type of care received. This will be determined by the sending health careprovider’s protocol.If you are not the patient, describe your relationship and legal authority to sign on behalf of the patient. In some cases, youmay be required to provide legal paperwork verifying your legal authority (e.g., court-appointed guardian, power of attorneyfor health care). Check with the sending health care provider’s office regarding these requirements.Alice Peck DayHealth InformationServices10 Alice Peck Day Dr.Lebanon NH 03766Ph:Fax:(603)(603)448-7433640-1984Cheshire Medical Concord DHMedical ReleaseCenterHIM Dept.590 Court St.Keene, NH 03431Ph: (603) 354-5477Fax: (603) 354-6530Health Information Services:Dept.253 Pleasant St.Concord, NH 03301Ph: (603) 229-5145Fax: (603) 229-5146EFMC:DHMCManchester DHNashua DHRelease of InformationOne Medical CenterDr.Lebanon, NH 03756Ph:Fax:(603)(603)650-7110727-7869Health InformationServices100 Hitchcock WayManchester, NH th InformationServicesRelease of Information2300 Southwood Dr. 273 County RoadNashua, NH 03063New London, NH 03257Ph: (603) 577-4037Ph: (603) 526-5247Fax: (603) 577-4039 Fax: (603) 526-5051New LondonDo Not Scan to eD-H Medical Record
Two identifiers neededI hereby designate the following Personal Representative to assist me in exercising my health information rightsunder the New Hampshire Patients’ Bill of Rights and the federal HIPAA Privacy Rule, as indicated below:NameRelationshipAddressPhone NumberVerbal Conversations:I permit the staff at Dartmouth-Hitchcock (comprised of Mary Hitchcock Memorial Hospital and DartmouthHitchcock Clinics); Cheshire Medical Center; Alice Peck Day Memorial Hospital (APD); and New LondonHospital, including Newport Health Center (NLH); to discuss my protected health information, in person or bytelephone, with the person named above. This includes the ability to make, cancel, or reschedule appointmentson my behalf and assist me in making payments or inquiring about my billing account.Other:In addition, I grant my Personal Representative the following: Proxy access to my “myD-H” patient portal account; The ability to request or receive paper or electronic copies of my medical records The ability to authorize use or disclosure of my protected health information; If my Personal Representative is an employee of Dartmouth-Hitchcock, Cheshire Medical Center, orAPD, the ability to access my entire medical record electronically.I understand and acknowledge that the protected health information I am authorizing Dartmouth-Hitchcock,Cheshire Medical Center, APD, and NLH to share with my Personal Representative may contain drug/alcoholabuse, mental health, HIV, and/or genetic testing information.I understand and acknowledge that this designation applies to all clinical areas of Dartmouth-Hitchcock,Cheshire Medical Center, APD and NLH.This authorization shall remain in effect until I send a written request to revoke to Dartmouth-Hitchcock,Cheshire Medical Center, APD, or NLH Health Information Services. Submitting a new form will revoke anexisting form.Patient’s Printed NameDateSignature of Patient or Legal RepresentativeLegal Representative’s Name (if applicable)“Dartmouth-Hitchcock Health (D-HH)” is the corporate parent of the covered entities listed below, each of which is an individual corporate entitylegally separate and distinct from Dartmouth-Hitchcock Health. Member organizations include: Alice Peck Day Memorial Hospital, Cheshire MedicalCenter, Mary Hitchcock Memorial Hospital and D-H Clinic, operating jointly as “Dartmouth-Hitchcock,” Mt. Ascutney Hospital and Health Center,New London Hospital, and the Visiting Nurses and Hospice for VT and NH. The D-H ACE comprises only of D-HH members who are currentlyusing a single, integrated electronic medical record system, sometimes referred to as “eD-H.”Health Information Services Approval: 2/14/2020EFMC Approval: 7/11/2019Scan to: Designated Personal Representative
Name:DateDOB:Script NamePrinted NameSignatureStaff Initials
NLH PROVIDERSAUGUST 2021BEHAVIORAL cki Anderson, PSYNadee Siriwardana, APRN603-526-5162Andrew Torkelson, MD Jonathan C. Waltman, MD*GASTROENTEROLOGYGENERAL SURGERY603-526-5172Catherine Schneider, MD Lauren Wilson, MD*Sean D. Bears, MD*Rodwell Mabaera, MD*GYNECOLOGY603-526-5172603-526-5450Siddhartha Parker, MD, MA*Eileen Kirk, MDDERMATOLOGY603-650-3100Emily E. Shaughnessy, MD*SPINE/NEUROSURGERY603-526-5408Hulda Magnadottir, MD Joseph M. Phillips, MD Harold J Pikus, MDOPHTHALMOLOGYAlyssa M. Pearl, PATimothy C. Ryken, MD*OTOLARYNGOLOGY (ENT)603-526-2020603-526-5172David Lawlor, MDSarah Seo, MD*PAIN MANAGEMENT603-526-5162Janice E. Gellis, ram Kalpakgian, PA-C Sarah Stuart Lester, MDLin Brown, MD*PRIMARY CARE: INTERNAL MEDICINEOSTEOPATHIC MANIPULATIVE MEDICINEElaine M. Silverman, MD Rebecca Wood, MDBrian J. Frenkiewich, nce M. Dagrosa,MD*Michael Grant, MD**Dartmouth-Hitchcock ProviderNew London Hospital 273 County Road, New London, NH 03257 603-526-2911 NewLondonHospital.org
PRIMARY CARE: FAMILY MEDICINE603-526-5544Christine Dube, MS, Brian J. Frenkiewich,APRNDOGriffin Manning, APRN John Malcolm, MDNEWPORT HEALTH CENTER603-863-4100INTERNAL MEDICINEOliver Herfort, MDGYNECOLOGYEileen Kirk, MDFAMILY MEDICINEAmanda Dostaler, DO Benjamin Holobowicz,JR, MPAS, PA-CPEDIATRICSRebecca L. Lozman-Oxman,DNP, CPNP, MPHMelissa M. Nelson,MSN, APRNShannon Schachtner,APRNORTHOPAEDICSRichard “Pete” Peterson,PA-C, ATCDARTMOUTH-HITCHCOCK ORTHOPAEDICS AT NLH603-526-5314James B. Ames,MD, MSJohn-Erik Bell, MDKevin D. Dwyer, MDDavid S. Jevsevar,Elizabeth B. Leatherman, Allison A. MacKay,MD, MBAMMS, PA-CMSN, APRNKathey A.Fortin,MSN, APRNKevin J. McGuireMD, MSJan Idzikowski,PA-CVincent D. Pellegrini, Jr.,MDFrances D. Faro, MDSarah M. Trainor,MSHS, PA-C*Dartmouth-Hitchcock ProviderNew London Hospital 273 County Road, New London, NH 03257 603-526-2911 NewLondonHospital.org
PATIENT INFORMATION Complete each box as indicated with the following information: · Patient s name (please print clearly) · Patient s date of birth · Patient/Personal Representative s phone number · Patient s m ailing address, including City, State, and Zip Code SENDER
Destination Newport is the city of Newport’s all-volunteer designated marketing committee that meets monthly on the third Thursday at 2 p.m. at City Hall, unless otherwise noticed. The organization serves the interests of Newport’s tourism economy by marketing the city of Newport as an all-season visitor destination.
Newport Bay is located on the southern California coast, approximately 40 miles south of Los Angeles. From the harbor entrance Newport Bay extends about 3.5 miles north northeastward. Newport Bay is a combination of two distinct units, termed "Lower Bay" and "Upper Newport Bay” (UNB), divi
The Newport Programs and all materials furnished or produced in connection with them ("Related Materials") contain trade secrets of Newport and are for use only in the manner expressly permitted. Newport claims and reserves all rights and benefits afforded under law in the Programs provided by Newport Corporation.
Stark . 101.847 : 2 . Jackson Local : Stark . 101.392 : 3 . North Canton City : Stark . 100.742 : 4 . Northwest Local : Stark . 99.288 : 5 Tuscarawas Valley Local .
submitted by Stark Pharmacy pursuant to OIG’s request, whichever is later. C. The term “Covered Persons” includes: 1. all owners and employees of Stark Pharmacy; and . 1 Howard Stark Professional Pharmacy, Inc. d/b/a Stark Pharmacy, Gary Gray, and Steven J. Schafer Integrity Agreement
Stark Area Regional Transit Authority 1600 Gateway Blvd. SE Canton, Ohio 44707 We have reviewed the Independent Auditor's Report of the Stark Area Regional Transit Authority, Stark County, prepared by Watson, Rice & Co., f
Community News) Tue 26 Feb Pittwater High School Open Night (see flyer in Community News) Sports. Newport Swimming Carnival. Tuesday 19 February is the Newport Swimming Carnival, please ensure that students who are attending the carnival are at school no later than 7.45am so that we can board the buses by 8.10am. Students can wear their sports .
1. Introduction The project applicant, Uptown Newport LP, is seeking approval from the City of Newport Beach for development of the Uptown Newport mixed-use develo pment. The proposed proj ect would develop 1,244 residential units and 11,500 square feet of retail on a 25.05-acre site currently occupied by the Jazz Semiconductor, Inc., facility.
