Please take care to fill out this form accurately. Incorrect information will slow process time dramatically and/or result in a correction made at a later date.
Please note that Preferred Primary Care teams are part of the following organizations:
Blue Hill Hospital · CA Dean · Eastern Maine Medical Center· Inland Hospital · Maine Coast Hospital· Mercy Hospital · Sebasticook Valley Hospital · AR Gould Hospital · Mayo Regional Hospital · MDI Hospital · Northern Maine Medical Center · InterMed · Martin’s Point · Newport Family Practice
__ I do hereby attest that the information I provided above is true and correct. __ I understand that knowingly making a false statement is a violation of the Northern Light Health Code of Conduct, and as such may lead to discipline, up to and including termination of employment when deemed appropriate. __ I understand that submitting this disclosure form is considered my electronic signature and is a legal document.
A copy of your submission will be sent to the email address indicated above – please double check that you typed it in correctly. Please retain your emailed copy for your records.