State of New Hamphire
Department of Health and Human Services
Division of Community Based Care Services
Bureau of Developmental Services
105 Pleasant Street, Concord NH 03301
DCBCS
>>
BDS
NHDHHS Autism Spectrum Disorder Registry Reporting Form
PATIENT INFORMATION
*
Patient's first initial of last name:
*
Last 4 digits of
Patient's
SSN#:
*
Birth Date (mm/dd/yyyy):
*
Gender:
M
F
*
Residence at Birth:
(City/Town)
(State)
*
NH Residence at time of diagnosis:
(City/Town)
*
Ethnicity/Race:
White (Non Hispanic)
American Indian/Alaskan Native
Black (Non Hispanic)
Native Hawaiian or other Pacific Islander
Hispanic
Asian
Not Reported
Other
Other (please Specify):
DIAGNOSIS INFORMATION
*
Diagnosis (select one):
Autistic Disorder
Asperger Disorder
PDD-NOS
Rett Disorder
Childhood Disintegrative Disorder
*
Date of Diagnosis (mm/dd/yyyy):
REPORTER INFORMATION
*
Name (First, MI, Last):
*
Degree (select one):
M.D.
PhD
M.A.
M.S.W
D.O.
Psy D
M.S.
Other
Other (please Specify):
*
License Number:
*
Email or Postal Mail Address:
If you have any questions please feel free to contact Peggy Sue Greenwood at:
Phone: 1-800-852-3345, Ext. 5034 (NH only) or (603) 271-5034 Fax: (603) 271-5166
All fields are required.
Print a copy for your records before submitting the report.
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