Our staff would be happy to answer any questions or to provide you with a hard copy of any document.
Release of Information for Current Patients
- Medical patients: Fill out entire form
- Dental patients: Initial only the second item on the list in middle of the page.
Income Info & Sliding Fee Scale Application
Behavioral Health Forms and Documents
- Download a PDF
- Print it out and fill it in
- Mail it to your health center or drop it off:
– Families First, 8 Greenleaf Woods Drive, Portsmouth, NH, 03801
– Goodwin Community Health, 311 Route 108, Somersworth, NH 03878
Use this form to ask us to send you a renewal packet in the mail.
- Download a PDF in your language:
Espanol | Portuguese | Tiếng Việt | Người Bồ Đào Nha - Print it out and fill it in.
- Mail it to your health center or drop it off:
– Families First, 8 Greenleaf Woods Drive, Portsmouth, NH, 03801
– Goodwin Community Health, 311 Route 108, Somersworth, NH 03878
– Lilac City Pediatrics, 180 Farmington Road, Rochester, NH 03867
Regardless of which option you choose:
One of the forms asks you to acknowledge that you have been given access to the following documents. Please click the links below to read them.
