Following is a list of forms you may need as a DMC Primary Care patient. If you have questions or are looking for information not listed here, please call us at 603.537.1300.
***PATIENTS OF DR. AJAY KOSHY, WELCOME TO DMC!***
TO FILL OUT AND SUBMIT YOUR RELEASE OF MEDICAL RECORDS FORM, PLEASE CLICK HERE: Authorization Form for Use and Disclosure of Protected Health InformationDR_KOSHY
Release of Medical Records Form:
- Electronic Version [ADULT]: Authorization form for Use and Disclosure of Protected Health Information
- Electronic Version [MINOR]: Authorization Form for Use and Disclosure of Protected Health Information
- Printable Version [ADULT]: Authorization Form for Use and Disclosure of Protected Health Information (PDF to print and mail OR bring in)
- Printable Version {MINOR}: Authorization Form for Use and Disclosure of Protected Health Information (PDF to print and mail OR bring in)
Other Forms for All Patients:
- Printable Version: Personal Information/Lab Results Authorization
- Electronic Version: Personal Information/Lab Results Authorization
- Cologuard Order Requisition Form
- Notice of Patient Privacy Practices
- Patient Information and Authorization for Use of Electronic Mail
- Testing Procedure Instructions for Mammogram, Ultrasound, Stress Testing (ETT) and Echocardiography
- Electronic Release Form for Minor
- Medical Release Form (Minor): PDF for printing Protected Health Information