Forms

Welcome to Life Long Care of New London!  Before your first appointment, please complete the following checklist.  We look forward to seeing you and working together to reach your health care goals.

1. Change your primary care provider with your insurance company prior to your visit.

If you have a HMO insurance, please ask your insurance company to list Elizabeth Falicon, APRN as your primary care provider, even if you are seeing another provider.

If you are unsure which provider you would like to see, please visit our website to read a short bio on each provider. Please call if you’re still unsure, we would be happy to help.

2. Please print out and complete our Patient Registration Form. If you are unable to print any of our forms, please call our office at (603) 526-4144 and we will mail you the required forms. The Patient Registration Form includes demographic information, Authorization to Treat and our Release of Information form. Only the names listed on the Release of Information Form will be allowed to communicate with our office regarding your health care.

3. To allow us to request your medical records from your previous provider(s) please complete our Record Release Form.

4. Once we have your completed Patient Registration and Record Release Forms, we will request your records and call you to set up an establish care appointment when your previous records are received. 

Establish Care Appointments are for reviewing health history and immediate concerns if time allows.

5.  Please bring your insurance card and co-payment to your first visit.

6.  Please review our Policies. 

7. Please review our Notice of Privacy Practices. 

Record Release

TO

Life Long Care of New London

Patient Registration Form

Notice of Privacy Practices

 Policies

NH Walking Disability Form

Advanced Care Planning Guide

Record Release

FROM

Life Long Care of New London