Additional Information

You will find these forms helpful for registering as a new patient with St. Joseph Hospital Adult Medicine, understanding your rights as a patient, and having your records forwarded to St. Joseph Hospital Adult Medicine from another doctor’s office. 

Permission to Speak/Authorization to Discuss PHI? (pdf file) 

Forms: 

Authorization to Release Medical Records (pdf file)
Fill out this form and send it to your former provider to authorize that office to release your medical information to St. Joseph Hospital Adult Medicine.

OR

Fill out this form and send it to St. Joseph Hospital Adult Medicine to authorize the release of your medical information to a new provider.

Next of Kin Authorization to Release Medical Records (pdf file)
Medical History Questionaire (pdf file)
Allergy Skin Testing Instructions (pdf file)

Other:    

St. Joseph Hospital Privacy Statement
St. Joseph Hospital’s Privacy Statement is a comprehensive document designed to inform you about the guidelines and regulations that govern St. Joseph Hospital and it's affiliates use of your Personal Medical Information. 

http://healthnet.umassmed.edu/topics/endoflife.cfm
http://www.healthynh.com/downloads/endoflife.pdf 
The above web sites are good resources for information on advance directives and living wills.

Insurance and Billing

St. Joseph Hospital Adult Medicine accepts most major insurance plans and will submit claims to your insurance carrier. To help us keep your information current, please bring your insurance ID card to every appointment. Co-pays are due at the time of service.

As all insurance plans differ, we encourage you to familiarize yourself with the guidelines of your plan regarding prior authorization and referral requirements. Additionally, routine services such as physical examinations may not be covered by all plans. It is your responsibility to know and understand your insurance plans requirements and covered services.

Please note you will receive separate bills for hospital, laboratory and/or radiology services. Please contact the facility listed on your statement with any billing questions for those services.

We utilize a Central Billing Office whose staff is available to answer any questions you may have regarding office charges and the billing process. Our Central Billing Office can be reached by calling (603) 578-5090.

Should you have any questions regarding a hospital bill, please call Patient Accounts at St. Joseph Hospital (603) 595-3975.

Free Care

Free care is available for patients who qualify. If your family's income is less than 300% of the Federal Poverty Income Guidelines, you may qualify for assistance with all or a portion of your self-pay balance. You may inquire about this program before you arrive or at the time of registration. You may also inquire after receiving your statement. Free Care Application >>