New London Medical Group

273 County Rd, New London, NH 03257

(603) 526-5544

Dear Patient,

Thank you for choosing the New London Medical Group for your medical needs. Our

goal is to provide you with quality care every time.

To ensure that your New London Medical Group 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 New London Hospital Medical Records

Department.

The following providers are available to see new patients in the areas of infancy to

elderly care:

Elaine Silverman MD (Adult Only)

Christine Dube APRN

Brian Frenkiewich DO

Erin Knuuti APRN

John Malcolm MD

Rebecca Wood MD (Adult only)

Amy Schneider MD

Denise Weber MD (Adult Only)

Ashley Warner MD

Griffin Manning APRN

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.

If you have any questions, please contact us at 603-526-5544.

The New London Medical Group 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 Medical Group

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 #: PP11 *PP11* 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 #: PP11 *PP11* 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) ?

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:

New London Hospital Medical Group Address 1: Address 1:

273 County Rd

Address 2: Address 2:

City:

State:

Zip:

City:

New London State:

NH Zip:

03257 Phone: Fax: Phone:

603-526-5191 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:

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

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