Patient Forms

Patients can download forms by clicking the following links:

• Patient Registration
• Medical History
• HIPAA Privacy
• Acknowledgement of HIPAA Receipt
• Diet for 3 Hour Glucose Test
• Instructions for Pelvic Ultrasound
• Instructions for Sonohysterograms
• Instructions for Obstetrical Ultrasound
• Release of Medical Records
• Patient Financial Policy w/ Signature
• Patient Financial Policy
• No Show Policy

Our fax number is 603-924-8709.

Billing

For billing questions, please call 603-924-3088.

We accept the following forms of insurance:

Commercial Insurance

• Aetna
• Ambetter
• Anthem
• Cigna
• CHN PPO Consolidated small group
• Coventry Health Care National Network
  • Mail Handlers
  • First Health
• Harvard Pilgrim
• First Health Network
• Maine Community Health
• Martin's Point
• Multi Plans/PHCS Network
• Tricare
• Tufts Health Plan (Freedom Plan) and Tufts Carelink (not Tufts HMO)
• United Health Care

Government Insurance

• Medicaid (Xerox)
• Medicare
  • Humana (Medicare Plan)
• NH Healthy Families
• Wellsense

HMO patients need a referral for all visits excluding annual well woman exam and pregnancy.

If you have a question regarding our office participation with your insurance plan, please call our office at 603-924-3088.