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Friends of NCHC
Urgent Care Centers
Insurance referral forms (to see a specialist or receive
a service) - to
ensure that we have been able to process them correctly with your insurance
Insurance that requires a referral
please fill out and return this form: General
Please submit ALL information on this form by printing
the above document and faxing it to 603-642-6701, dropping it off or Emailing it to
firstname.lastname@example.org with ALL
the information completed. Failure to complete may result in a delay
of your referral and causing you to have to pay for you specialist visit.
Medical Release Form (to have a copy of your records sent
If you have left our practice we recommend that you request a copy of
your records to be picked up or sent to yourself. We suggest this as
it is our office policy to only provide your record once free of charge, subsequent
requests will be charged a fee per page. For example if you leave our
practice and request that your records be transferred to your new PCP, Dr.
X. We will copy and send your records to Dr. X. If you become
unhappy with Dr. X or he/she leaves or closes their practice or anything
else happens that results in you needing to request another copy of your
records we will charge a fee per page for your record to be copied.
However if you request your records to go to yourself you can make as many
copies as you wish to go to as many doctors as you wish over your lifetime
giving you better continuity of care. Please fill out our MEDICAL
RELEASE FORM and submit it to our office. Allow 14 business days for
your request to be completed.
If you are a current patient of the practice, and are not leaving our
practice, but you need some or all of your records released to another entity
(insurance company, research study, etc) and that entity has not asked you
to sign a medical release form please fill out our MEDICAL RELEASE FORM and
submit it to our office.